Manager - Operations Claims

About the Role

This position is dedicated to ensuring seamless coordination with service provider partners for the prompt resolution of travel and OPD claims. The role requires the candidate to perform routine medical and technical audits on claims settled by partners, maintain accurate management information systems (MIS), and generate relevant reports. The job is part of the Financial Service – HO business unit at Aditya Birla Health Insurance Company Ltd, located in Thane under the Services Operations function and specifically in the Claims department.

Job Purpose

The role is centered on guaranteeing the timeliness and quality of claim processes and audits. The successful candidate will manage turnaround times (TATs) according to defined service level agreements (SLAs) and maintain claim process quality.

Job Context and Challenges

Ensuring adherence to quality standards in claim processing and audit while effectively managing TATs presents operational challenges. Strong coordination and proactive problem-solving skills are needed to meet internal and external expectations.

Key Responsibilities

• Accurately and promptly submit both periodic and ad-hoc claims reports, utilizing advanced Excel shortcuts, formulae, and alternative tools to improve efficiency.
• Conduct preliminary reviews and sanity checks of reports prior to submission.
• Address audit observations through targeted training of partner claim processors on policy terms, time management, and delegation.
• Collaborate closely with internal teams and external stakeholders for monthly, quarterly, and annual data reporting.
• Work with external data teams to manage reports such as LDR monitoring, daily intimation, monthly TAT MIS, and OPD FWA savings data.
• Supervise debit note processes related to payments from TPAs and OPD partners, ensuring all transaction details meet specified criteria (e.g., correct dates, policy validity, amounts).
• Coordinate MVP implementations with OPD partners including automation of FWA triggers, ICD 10 coded data integration, and promoting home collection in health check-ups.
• Align automated claim adjudication rules with company processes and enable real-time client dashboards for review.
• Provide system access to ABHI for claim approval and ensure communication and reporting adhere to ABHI standards and formats.
• Manage query handling with deficiency options and ensure medicos process OPD claims effectively.
• Drive data digitization, API integrations, and define limits/sublimits within partner systems to prevent overutilization.
• Ensure portals reflect accurate wallet balances per insured/family and validate utilizations against opted sum insured.
• Oversee end-to-end portal access for cashless claims and daily claim outstanding report dissemination.
• Facilitate symptom linking prior to consultation slot booking.

Relationship and Interaction

The role demands continual interaction with the internal MIS team to coordinate data requirements and tailor MIS templates for partner payment processing. External partnerships require periodic engagement to review claims decisions, reconsiderations, and system development or enhancements beyond the partner processing team's authority.

Organizational Reporting

The position reports directly to the Manager or Senior Manager within the Services Operations function in Claims.

Workforce and Scale

• Business On-Roll Employees: 6000+
• Business Off-Roll/Part-Time: 4000+
• Unit On-Roll Employees: 6000
• Unit Off-Roll/Part-Time: 4000+
• Function On-Roll Employees: 800
• Function Off-Roll/Part-Time: 279
• Department On-Roll Employees: 69
• Department Off-Roll/Part-Time: 66