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.
- Collabo

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