As a Manager Claims, your typical week might include the following:

- Guiding processing team by providing medical opinion for Health Insurance Claims

- Ensure claims of valid settlements are made according to the company practice and procedures.

- Processing and approving medical claims pertaining to Indemnity, Benefit for both Group and Retail, with sharp FWA and Loss minimization approaches.

- Thorough on the compliance and regulatory requirements and implementation in the claims process.

- Creating detailed standard operating process for seamless functioning of claims adjudication

- Case management of potential cases to Network team, maintaining data of referred/saving achieved/impact against cashless outgo.

- Automation and rule driven decision making with timely update of benefit in TAT / TMS / Transaction

- Create and reviewing claim simplification guidelines to Improve TAT, Minimize transaction.

- Manage floor people and SLA (TAT) create roster, manage adequate manpower on daily basis, especially on weekends and public holidays.

- Audit of TPA processed claims and also Inhouse processed claims.

- Medical decisioning and guidance to the team

- Analytics and Dashboard Dashboard preparation to Manage TAT, Cost vector (ACS, Pay-out ratio), Loss ratio, CS:RI ratio and regional distribution.

- Support to Group UW team for providing claims analytic input like Specific trend related to FWA, Frequency, Loss ratio, utilization of particular benefit.

- Regulatory compliances Claim processing guideline as per compliance and timely implementation of any New Circular.





- Litigation cases Claim related to Input and evidence in SCN (Self-containment note) to make our stand stronger in Ombudsman/any other legal forum.

- Train TPA teams – Timely Training of TPA for recent benefit, process change, Understanding and claim Philosophy as per PHI standard.

- Benefit claims – Well versed with processing of Benefit claims, Creating SOP, Pay-out framework to Nominee/Legal heir.

- Collaborate with FWA Manager to provide inputs from agencies for efficient Fraud restriction and necessary checks and balances in system.

- Re-UW opinion for non-disclosure cases – Training to Team for indicated cases for Re-UW referral, tracking and corrective action basis UW decision.

- Extend support to the sales/distribution – Separate prioritization que for Green channel, Specific Agent, Broker.

- Set up and create robust governance to manage TPA process with great efficiency.

- Proficient with medical terms & systems (including ICD/CPT/PCS codes).

- Collaborate with Underwriting, Actuarial, Finance and other stakeholders to ensure knowledge sharing on market trends, legal changes, and loss developments.

- Drive FWA process end to end (Referral % , Success % , Impact % ) , Managing FWA agency,



Managing FWA TAT and report quality.

You could be the right candidate if you

- Are a doctor by training (MBBS preferred /BAMS/BHMS/BDS)

- Have 10-15 years’ experience of health Insurance claims management with at least 2-3 years’ experience in Manager role.

- Understands the TPA ecosystem and has experience of managing TPA model (Preferred)

- Have startup experience or setting up a team from scratch (Preferred but not mandatory)

- Should be a decisive & creative individual.

- Should be able to make quick decisions and have good judgment and analytical skills

- Have an excellent verbal and written communication skills and strong negotiation skills.

- Always open to embracing change and be able to manage it

- Managed team with people from Medical and Non-Medical background

This could be the gig for you if you

- Are passionate about consumer behaviour and culture; enjoy spending time with customers to understand what they really want. Have an attentive ear listen to new ideas.

- Like to work in a culture where everyone can see what others are doing

- Take help from others when stuck and encourage others when there are setbacks

- Take full responsibility for your own output while thinking wing to wing across the organization; to solve for the customer

- Have strong clinical knowledge and clinical decision-making skills

- Have built best in class processes from a scratch.

- Are passionate about leveraging digital tools to transform customer experience What can make you extra special.

📌 Claims Manager (Mumbai)
🏢 Prudential HCL Health Insurance
📍 Mumbai