DM-Claims (Thane)

Role overview

This position sits within the Claims function for Aditya Birla Health Insurance Company Ltd in Thane. The role is focused on coordinating with a service partner team to ensure timely settlement of travel and OPD claims, performing medical and technical reviews on claims approved for settlement, and maintaining accurate MIS and reporting for the claims process.

Basic details

• Business: Financial Service – HO
• Unit: Aditya Birla Health Insurance Company Ltd
• Location: Thane, Maharashtra
• Position title: Assistant/Deputy Manager - Claims
• Manager title: Manager/ Sr. Manager
• Function: Services Operations
• Department: Claims
• Designation: Assistant/Deputy Manager
• JD updated on: 08.01.2024

Job purpose

The job exists to make sure travel and OPD claims are settled on time in coordination with the partner team. It also requires periodic medical and technical audits of approved claims, along with ownership of claims MIS and related reporting.

Dimensions

• Business workforce size: On roll 6000+, off-roll/part-time 4000+
• Unit workforce size: On roll 6000, off-roll/part-time 4000+
• Function workforce size: On roll 800, off-roll/part-time 279
• Department workforce size: On roll 69, off-roll/part-time 66

Job context and challenges

The main challenge is to maintain claim quality and audit accuracy while meeting turnaround times as per the agreed SLA.

Key result areas

• Submit periodic and ad-hoc claims reports accurately and on time.
• Use Excel shortcuts, formulas, and alternate tools or methods to speed up report preparation, and perform basic checks before sending reports.
• Close audit observations through training partner claim processors on policy terms and conditions, time discipline, and delegation practices.
• Work closely with internal and external stakeholders for monthly, quarterly, and annual data submissions.
• Handle data and MIS activities, including support on LDR tracking, daily intimation reports, monthly MIS checks for TAT, and OPD FWA savings data.
• Monitor debit notes and payment checkpoints for TPA and OPD partner payouts, ensuring critical validations such as admission, discharge, policy dates, intimation dates, claim amount, and remarks are correctly reviewed.
• Support MVP implementation with OPD partners, including automated FWA triggers, ICD-10 coding, home collection preference for health check-ups, FWA investigation coverage, automated adjudication rules, client dashboards, ABHI system access, ABHI-format letters and vouchers, report digitization, API integrations, limit controls, wallet/sub-limit validation, and end-to-end portal access for cashless claims.

Relationships

• Internal MIS team: Ongoing coordination to collate data and align templates for partner payment processing.
• External service providers/partners: Intermittent coordination to decide on claims, reconsideration cases, claims beyond partner authority, and process enhancements.

Organizational notes

• The job documentation includes a sign-off section for the job holder and the reporting manager.
• The hard copy of the JD is required to be maintained in organizational records.

Additional information

• Job purpose for direct reports: NA
• Poornata position number and reports-to position number were listed but not specified in the source.

Sign-off requirement

Sign-off is required on the hard copy of the JD by the manager and the job holder.