Job Description:

Primary Role Description: - Responsible for leading claims-focused training, learning & development, and quality management across Financial and Medical claims operations. The role ensures high-quality, compliant, and productive claims processing through robust training frameworks, continuous learning initiatives, and quality assurance programs.

Key Roles & Responsibilities:
Design and deliver structured training programs for Financial and Medical claims processing teams.
Develop claims curricula, SOPs, job aids, and refresher modules aligned with regulatory and company standards.
Creation, periodic review and update of claims quality management plan
Sample based review of medical and financial adjudication to identify errors and plan mitigation
To ensure existence of a no critical error and minimal non-critical error process.
Coordinate with internal audit team to plan and execute periodic claims audit
Run clinical governance across all functions housing clinical experts.
Implement and manage claims quality assurance frameworks, audits,



and root cause analysis.
Monitor claims accuracy, compliance, turnaround times, and customer impact metrics.
Partner with Operations, Medical, Finance, Compliance, and Technology teams to address quality gaps and process improvements.
Drive continuous learning initiatives, certifications, and upskilling for claims specialists.
Track training effectiveness and quality outcomes using KPIs, dashboards, and reporting.

Key Requirements:
Prefer MBBS Graduate/Postgraduate in Healthcare, Insurance, Finance, or related field
8–12 years of experience in Health Insurance Claims, with exposure to Training and Quality functions
Solid understanding of Health Insurance claims—Financial and Medical
Expertise in Claims Quality Management and Audit Processes
Learning & Development / Training Design experience
Knowledge of regulatory and compliance standards
Analytical, stakeholder management, and communication skills

📌 Gm/avp Quality Management And L&d Noida (India)
🏢 Mancraft Consulting
📍 India