Basic Details: Fill the required information about business, unit, location, position, reports to position and date of updation of JD

Business

Financial Services

Unit

Aditya Birla Health Insurance Company Ltd

Location

MBC, Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job

Head – Provider Network

Reports to: Poornata Position Title

Chief Operating Officer

Function

Operations

Reports to: Function

Operations

Department

Ops – Provider Network

Reports to: Department

Operations

Designation of the Employee

Vice President

Designation of the Manager

Executive Vice President

Date of writing/updation of JD

Jan 2024

1) Job Purpose: Write the purpose for which the job exists (in 2-3 lines)

The role is responsible to lead the designing and execution of strategy for Provider Network of ABHI and will be responsible for managing partner relationship, expansion of hospital network to all possible location having policy distribution, controlling the ACS (Average claim size), Negotiating the tariffs with hospitals and creating preferred provider network having package-based pricing for possible services. Managing OPD / wellness partners and TPAs through health claims, PPMC, D/HA and Health checks and its related commercials, evaluating new health tech partners and ensuring the deliverables for customer servicing. The role will also be responsible for creating and managing DC network (Diagnostic centers) PAN India through the aggregator or direct partners.

2) Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.

Business Workforce Number
(Max 254 Characters)

On Roll – 6000

Offroll/ Partime - 4000

Unit Workforce Number
(Max 254 Characters)

On Roll – 6000

Offroll/ Part time - 4000

Function Workforce Number
(Max 254 Characters)

On Roll – 800

Offroll/ Part time - 200

Department Workforce Number
(Max 254 Characters)

On Roll – 23

Offroll/ Part time – 4

Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

Manage & Direct Processing of transactions

India Head – Provider Network (August 22 to till date).

Coverage of No. of Hospitals in Network /Cities

FY 22-23- 10693 / 983,

FY 23-24- 11180 / 1095,

Span of the role

No. of Other Providers (Diagnostic Centre, Consultant, Pharmacies) in Network /Cities

FY 22-23- 6800 / 2036

FY 23-24- 7708 / 2308

No. of TPAs/ Institutional Partners

FY 22-23 – 12 / 06

FY 23-24 – 12 / 09

No. of Annual Health Checks/PPMC

FY 22-23 – 37182 / 3941

FY 23-24 – 24289/ 6573

Processing Parameters

Managing Claim and Other Payout / volume to PN relationships

FY 21-22 – 405 Cr / 57,380.

FY:22-23 – 364 Cr / 48,498.

Vendor Management

OPD Insurance product and partner management

Group wellness and OPD business through aggregator partners offering digital / tech platform-based journey for customers. Having pre-defined network of doctors, pharmacy, diagnostics centers, dental, vision, vaccination, mental health, fitness centers - Gyms, yoga centers, & nutrition services.

3) Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section

About the Health Insurance Industry –

While the current market sees more than 15 non-life players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 25,000 Crs sees close to 80-85 % of the business renewing with the existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market. With the SME and the start-ups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardized solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them.

Market Opportunities – With the advent of medical advancements, lifestyle changes, change in Indian socio-economic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

About the Aditya Birla Health Insurance –

Aditya Birla Health Insurance Co. Limited (ABHICL), a part of Aditya Birla Capital Ltd. (ABCL), is a joint venture between Aditya Birla Group and MMI Holdings of South Africa. ABHICL was incorporated in 2015 wherein Aditya Birla Capital Limited (ABCL) and Momentum Metropolitan Strategic Investments (Pty) Limited (Formerly known as MMI Strategic Investments (Pty) Ltd.) were holding 51% and 49% equity shares respectively. ABHICL commenced its operations in October 2016 and is engaged in the business of health insurance.



Company’s current product portfolio includes unique offerings including chronic care and incentivized wellness. ABHICL became an associate company of Aditya Birla Capital Limited (ABCL) on October 21, 2022 post the allotment of 9.99% of equity shares of the Company to Platinum Jasmine A 2018 Trust, acting through its trustee Platinum Owl C 2018 RSC Limited (‘Investor’), an affiliate of Abu Dhabi Investment Authority (‘ADIA’). Consequently, Aditya Birla Capital Limited (ABCL) and Momentum Metropolitan Strategic Investments (Pty) Limited (Formerly known as MMI Strategic Investments (Pty) Ltd.) holds 45.91% and 44.10% of shares respectively.

As on H1 FY22 end, ABHICL recorded a gross written premium (GWP) of Rs.764 Crore and covered more than 16.2 Mn lives. ABHICL has nation-wide distribution presence in over 2800+ cities through branches and partner offices, 11 bancassurance partners and over 51,120+ direct selling agents. ABHICL has scaled and diversified digitally enabled distribution through 40%+ agency growth with 175 branch locations, bancassurance available through 16,000+ branches, and 39+ digital partners covering 6 Mn.+ lives through 50+ contextual byte-sized products.

ABHI’s unique offering to market includes proposition includes –

A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy

A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1

ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.

ABHICL’s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.

Key Challenges

- Setting the Network: To meet the sales and customer requirement a pan India network of hospitals, diagnostic centers, pharmacies, consultants, and home care services is required. The size and speed of setting the network is key to enable sales and service the customers.

- Tariff Negotiations: The current healthcare market is provider driven as supply-demand equation favors the providers. Negotiating competitive tariffs is an industry wide challenge.

- Ensuring Quality of Service delivery: Managing and marinating the large size of network require regular training and quality check of providers

- System and Data Mgt.: In India the healthcare industry is largely unorganized and fragmented, it throws lot of challenges in maintain the proper records and information about facilities and the tariff in system.

- Automation/ Digital Adoption: Aditya Birla Health Insurance wants to be seen as a tech driven co. and committed to have an automated claim adjudication system. It requires to position to have integration with providers.

- Partner/ TPA Mgt and rate Negotiation: The industry eco system is very complex and ABHI works through many partners and TPA. Signing contracts, negotiating rates and monitor the performance is a regular challenge to be managed.

- Given the dynamic & highly exceptional nature of group business and retail policy servicing, design & implement Custom made solutions as per each Corporate client requirement’s, by applying knowledge of fundamentals, technical know-how & past experience, whilst operating within budgetary constraints.

- Manage exceptions & customization as per each client’s requirements & provide timely approvals for exceptions post analyzing impact of decisions, whilst operating within statutory, regulatory & organizational norms. Devise and implement controls to ensure compliance to the various norms & ensure 100% compliance.

4) Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)

Key Result Areas

Supporting Actions

Help create a quality pool of providers across the country within reasonable reach of the customers within minimum reasonable time frame to meet the business requirement – New empanelment

- Design the provider network strategy for the organisation
- Map the healthcare service provider point of contacts available at different parts of the country and align with ABHI’s market penetrations to ensure availability of a network hospital at the closest distance, at an optimum cost and business viability
- Responsible to create and manage network- through direct tie ups with hospitals and using TPAs.
- Ensure our provider network works as extended representatives of ABHI to ensure uniform and benchmark to ABHI customers

Drive the commercial negotiations with the providers to ensure the best deal for the end consumer and keep the ACS under planned number.

- Managing the overall healthcare spend for ABHI across providers through rate negotiation and strategic tie ups.
- Analysing the cost variances across the network, benchmark against the industry and accordingly take effective measures to control claim pay out to provider partners




- Though effective negotiations at the time of contracting and at the time of hospitalisation, keeping the ACS & loss ratio under control

Enhancing the cashless utilization for better customer experience.

- Common empanelment initiative under GIC/ IRDA coordination to add all non-network hospital having ROHINI code to enhance the network reach.
- Offering cashless in non-network hospitals to the customers intimating the hospitalization in advance.
- Ensuring best customer experience through regular quality surveys and managing hospitalization.

Ensure that team has well defined roles, training plans, and developmental initiatives from time to time.

- Making sure proper on boarding of team members and training related to their job role.
- Arranging continuous training program and learning opportunities in line with development plans.

Ensuring compliance and regulatory requirements are met all the time related to provider network area

- Driving ROHINI registration for hospitals
- · Due diligence and ongoing check to avoid provider related fraud and abuse
- · Process Control and quality check during empanelment of provider and service partners
- Ensuring the reconciliation of MISs with finance and reporting to regulator

5) Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

- Zonal – Provider Network role will be responsible for creating, developing & managing a comprehensive network of healthcare providers and partners across the Zone along with team members across assigned geography. The role will also be responsible to negotiate best tariff structure for ABHI and manage the renewals and relationships while being responsible for making sure delivery of quality services as per signed SLAs. Case management and spot negotiation to control the waste and abuse by provider through their billing system. Overall relationship management with providers is a key deliverable of this role.
- OPD & DC Network role is required to manage a comprehensive network of OPD healthcare providers through partners across the country and spectrum and deliver the best of class experience to the customer undertaking the OPD insurance as a product, AHC, D/HA and Pre Policy-Medical Checkup with diagnostics, hospitals & allied healthcare providers of different services. The role must ensure that this service and other value-based offerings are delivered at a reasonable cost to the organization. Also, to manage technology vendors, negotiating and managing them & designing the technology integration with health tech service providers like labs, pharmacy, Geo Mapping partners etc. The role will support all TPA relationships & account reconciliations with TPAs. The responsibility to create wellness solutions for corporates & affinity partners also lies with the role.
- Central Provider Network role will be responsible for supporting the provider empanelment and partners strategy, managing over all central provider operations, servicing, provider cost and quality analytics and spend management. Also will responsible to manage the team of professionals responsible for delivering best of the customer experience with providers of different services at reasonable cost. The role will also require working with other business teams, particularly with the claims and servicing team to manage claim cost and client servicing. Digital & IT automation - Managing automation in claim and provider management processes, with tariff digitization and automating the same in core system to enable auto adjudication of claim. Inter-departmental coordination with key stakeholders to deliver the required outcome i.e., IT, digital, legal and claims team.

6) Relationships: Describe the nature and purpose of most key contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type

Frequency

Nature

Internal

Corporate Underwriting Team

Claims Team

Customer Service Team

Pricing and Product Team

Sales Team

DRM Team

Legal & Compliance

Digital and IT

High

High

High

Medium

High

Medium

Medium

Medium

Supporting the TPA fees negotiation

Ensuring cost efficiency through effective provider negotiations

Resolving customer complaints and grievance through working with providers

Helping in building right pricing assumption and validating the product ideas

Providing on ground support through building high quality network, arranging events for group clients

Ensuring network availability and cost negotiation

Contract Designing and ensuring compliance to regulations

Ensuring system readiness and ensuring digital experience for providers and customers

External

Healthcare Providers

TPAs

Tech Partner

Group HR

Wellness Partners

Affinity Partners

Industry Forums and Association

High

High

High

High

High

High

Medium

Contract T&C;, Tariff negotiation, Ensuring customer experience at point of service – Hospitals, DC, Pharmacy, Clinics

Managing GHI policies and Empanelment

Integration and data exchange

Wellness Offerings, AHC & D/HA

Corporate offerings

Empanelment’s & VAS for Retail & corporate customers

Driving ABHIs agenda, discussion with hospitals, Nursing Home and Consultants associations

7) Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)

📌 Manager -PN (Indore)) (India)
🏢 Financial services
📍 India