- Responsible for Health claim processing (including End to End processing of claims) with Speedy decisions of all Health claims with strong eye on risk.
- Monitoring the TAT for the portfolio along with ensuring no regulatory TAT breach
- Expertise in reviewing claim documents, medical opinions and understanding policy terms and conditions
- Compliance to all Regulatory requirements and delivery in lines with the same
- Responsible for quality claim decisions within the agreed product guidelines and SLAs
- Understanding trends and liaison with internal stakeholders for exhaustive assessment of documents & facts of claim.
- Updating information in the claims system
- Responsible for all customer communication related to Health claims.
- Responsible for data management for all reports.
- Responsible for claims related complaints and walk in customers.
- Identify areas of improvement and take projects and delivery as per business objective
- Noting the trends of red flags, suspicious claims and reporting to management
- Providing regular feedback to underwriters on voided claims
- Risk assessment and triggering verification of suspicious claims
- Should be able to coordinate with FIU team, sales team, product team, legal team, complaints team, vendors etc for claims processing, escalations & litigation cases etc.
- Team management tracking team productivity, targets and ensuring regulatory TATs are not breached.
B Organizational Relationships Reports to - AVP
C Job Dimensions
Geographic Area Covered - Pan India
Stakeholders -
Internal
FIU team, sales team,
product team, legal team, complaints team
External
Customer/ Policyholder, Vendor
D Key Result Areas
Organization Process
Key Contribution To ensure quality & accuracy of Health Claim processes
- Good knowledge on insurance & products & ability to take claim decisions as per policy terms and conditions
- Ensure 100% quality completion of Claim decision
- Ensure all cases are received by the department as per the specified inter & intra department SLAs.
- Presenting case summary and representing to reinsurers, communicating with distribution stakeholders
- Ensure adherence to defined claims TAT & decision accuracy
- Mentor, guide & train new team members
- Ensure quality & accuracy of Claims process
- Sharing feedback and conducting meetings with the relevant stakeholders time to time
- Evaluate emerging trends, competition practices and propose recommendations to senior management
- Managing the entire team and responsible for End to end TATs of Health claims as per regulatory guidelines
E Skills Required
Technical
- Medical background- Education minimum MBBS/ BAMS /BHMS
- Experience insurance experience, life + Health UW/claims
- Effective presentation and interpersonal skills.
- Valuable system skills in Excel/Word.
- Multitasking
Behavioral Essential -
- Analytical & Excel Skills
- Communication skills
- Teamwork Skills
- Relationship Building skills
- Decision making skills