Team Lead - Cashless Claims

Overview

This role is focused on managing claims payments for both indemnity and fixed benefit claims within designated turnaround times and in compliance with IRDA regulations.

Company and Unit

Health Insurance Unit under Aditya Birla Health Insurance Company Ltd based in MBC, Thane.

Reporting Structure

The Team Lead reports to the Associate Vice President and the Head – Reimbursement/Cashless Claims and operates within Services Operations under the Claims department.

Job Objectives and Scope

• Oversee claims payments ensuring adherence to prescribed timelines and approval matrices.
• Ensure claims processing TATs include: Pre-authorization decisions within 2 hours or 30 minutes (for TPA claims), reimbursement within 5 working days, claim processing within 7 days, and grievance resolution within 15 working days.
• Maintain Average Claim Settlement (ACS) benchmarks for cashless, reimbursement, and combined claims.
• Lead claims audits and quality control both internally and for third-party administrators (TPAs).

Industry Context and Challenges

The health insurance sector is highly competitive with numerous private and national players. The market is largely renewal-driven, presenting challenges in acquiring new business, especially among SMEs and startups. There is a growing need to develop innovative, cost-effective, and standardized products targeting diverse customer segments. Customers increasingly view insurers as health advisors, requiring tailored solutions integrating wellness benefits to foster profitable growth.

Company Profile

Aditya Birla Health Insurance Co. Limited was established in 2015 as a joint venture focused on expanding health insurance access to a broad demographic. It differentiates itself through unique wellness and chronic care programs and employs a fully digital, paperless operational model.

Key Responsibilities

• Design and implement innovative claim processes, Standard Operating Procedures (SOPs), and protocols for internal and TPA-processed claims.
• Manage and develop team capabilities through structured training.
• Support systems development and conduct User Acceptance Testing (UAT) for Indemnity and Fixed Benefit products.
• Maintain consistent claims quality, turnaround times, and adherence to approval authorities.
• Conduct portfolio analysis to monitor profitability and minimize loss ratios.

Performance Metrics

• Monitor team performance, claims transactions, and turnaround times.
• Address escalations promptly and maintain quality benchmarks.
• Audit claims and recommend empowerment levels for claims officers.
• Review and update claims guidelines in alignment with competitors and business trends.

Direct Reporting Roles

Sr. Executive – Claims: Responsible for timely settlement of all valid claims within authority limits and IRDA timelines.

Key Interactions

• Internal: Regular coordination with New Business & Policy Administration, Legal, Sales, IT, Underwriting, Internal Audit, Provider Management, Product and Actuary teams for various claim-related processes and system support.
• External: Interaction with policyholders, vendors, external auditors, brokers, and partner TPAs for claim decisions and query resolution.

Documentation and Sign-off

The job description was last updated on 20th July 2021 and includes provisions for formal sign-off by the job holder and associated manager to be retained as organizational records.