Manager-ops Claims

Role overview

This position is part of the Services Operations function within the Claims department at Aditya Birla Health Insurance Company Ltd, based in Thane. The role focuses on coordinating with a service-provider partner team so that Travel and OPD claims are settled on time. It also requires carrying out regular medical and technical reviews of claims approved by the partner, along with maintaining claim-related MIS and reports.

Job context and challenges

The role is expected to uphold quality in the claims process and audits while keeping turnaround times within the agreed SLA.

Key responsibilities

• Ensure accurate and timely sharing of periodic and ad-hoc claims reports.
• Build and use Excel shortcuts, formulas, and alternative tools or methods to speed up report submission.
• Perform basic checks and validation before reports are sent out.
• Close audit observations by coordinating with the relevant stakeholders.
• Train partner claim processors on policy terms and conditions, time management, and delegation.
• Work closely with internal and external teams to support monthly, quarterly, and annual data submissions.
• Handle claims data and MIS, including coordination with external data teams for reports such as LDR tracking, daily intimation reports, monthly TAT MIS checks, and OPD FWA savings data.
• Monitor debit notes for payments from TPAs and OPD partners, including verification of required checks such as admission and discharge dates, policy validity, intimation timing, claim versus paid amount, and related remarks.
• Support MVP implementation work with OPD partners and coordinate with partner leadership and tech teams.
• Help drive automation and process improvements such as FWA triggers, ICD-10 coding, rule-engine alignment, real-time dashboards, system access for ABHI approvals, automated communication and payment outputs, query handling, report digitization, API integrations, and limit/sub-limit controls.

Relationships

The role works with the internal MIS team on an ongoing basis to coordinate and consolidate data requirements and to align on MIS templates for partner payment processing. Externally, it interacts with service-provider partners as needed to support claim decisions, reconsideration cases, claims beyond the partner team’s authority, and process or system enhancements.

Organizational details

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane

Function: Services Operations

Department: Claims

Current designation: Assistant/Deputy Manager

Manager designation: Manager / Sr. Manager

Updated on: 08.01.2024

Workforce and scale

Business workforce: On Roll – 6000+; Offroll/Part time – 4000+

Unit workforce: On Roll – 6000; Offroll/Part time – 4000+

Function workforce: On Roll – 800; Offroll/Part time – 279

Department workforce: On Roll – 69; Offroll/Part time – 66

Additional information

Job holder and reporting sign-off details are required for the hard copy of the JD, which must be retained in the organizational records. The document notes fields for the job holder name and signature, and the reporting manager name and signature.