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, Perk 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 Current 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