Claims Head — Health Insurance

Location: Mumbai (Goregaon West)

Experience: Required 5 years in health insurance claims

Department: Claims & Customer Experience

Employment Type: Full-time

About Us

We are a health-focused platform committed to simplifying the insurance and healthcare experience for customers. We aim to provide customers with transparent, responsive, and hassle-free support throughout their health insurance journey — especially during claims.

About the Role

As Claims Head, you will take end-to-end ownership of the health insurance claims process — from intimation through to final settlement and closure. You'll manage relationships with insurance companies, TPAs, and hospitals, lead a claims team, and act as the primary escalation point for complex or high-value cases. This is a high-impact role at the intersection of operations, relationship management, and customer experience, directly shaping how customers experience one of the most stressful moments of their healthcare journey.

Key Responsibilities

End-to-End Claims Management

- Own the complete health insurance claims lifecycle across cashless and reimbursement claims.
- Monitor claims from intimation through documentation, assessment, approval/rejection, settlement, and closure.
- Ensure claims are processed within applicable turnaround times (TATs).
- Review pending, delayed, rejected, and disputed claims, and drive corrective action.
- Develop SOPs and processes for efficient, consistent claims handling.

Claims Kavach (Proactive Customer Support)

- Lead our proactive claims-assistance initiative, offering proactive support during hospitalization and claims.
- Help customers understand the claims process, documentation needs, and policy coverage.
- Guide customers through cashless approvals, queries, deductions, rejections, and settlements.




- Identify potential claim issues early and intervene before they escalate.
- Partner with the IT & Product teams on automation and building an integrated claims system.

Insurer, TPA & Hospital Coordination

- Manage coordination with insurers, TPAs, and hospitals for smooth, timely claims processing.
- Coordinate cashless approvals, enhancements, queries, deductions, rejections, and settlements.
- Build and maintain robust working relationships with key insurer, TPA, and hospital contacts.

Escalation Management

- Own all critical and high-priority claim escalations, building a structured escalation matrix.
- Personally intervene in high-value, sensitive, or delayed claims and track them to closure.
- Conduct root-cause analysis on escalations and implement preventive measures.

Claims Quality & Audit

- Review claim decisions, deductions, rejections, and repudiations for accuracy and compliance.
- Conduct regular quality audits and build claim-quality dashboards and MIS reports.
- Track insurer/TPA-wise rejection and deduction trends, plus claims and loss ratios.

Team Management

- Build, manage, and mentor the claims team; allocate work by priority, complexity, and capability.
- Set KPIs, run performance reviews, and train the team on policies, process, and escalations.
- Foster a customer-first culture within the claims function.

Customer Experience

- Ensure a smooth, transparent claims journey and act as a single point of coordination.




- Personally handle sensitive or high-value customer cases.
- Track and improve claims CSAT and resolution TAT.

MIS, Analytics & Reporting

- Maintain regular claims MIS: volumes, ageing, TAT, deductions, rejection reasons, and more.
- Report insurer-wise and TPA-wise performance, hospital-wise issues, and escalation ageing.
- Track customer complaints, resolution TAT, and overall Claims Kavach performance.

What We're Looking For

Education

- Graduate / Postgraduate in any relevant discipline.
- Insurance qualifications (Licentiate / Associate / Fellow of Insurance Institute of India) are a plus.

Experience

- 5 years of experience in health insurance claims.
- Hands-on experience with both cashless and reimbursement claims, with a solid grasp of inclusions and exclusions across health products.
- Experience working directly with insurance companies, TPAs, and hospitals.
- Prior experience managing a claims team is preferred.
- Background in a broker, insurer, TPA, health-tech, or insurance distribution organization is an advantage.
- Familiarity with technology, AI, and process automation.

Skills

- Strong knowledge of health insurance claims and policy terms — exclusions, waiting periods, deductibles, co-pay, room-rent limits, etc.
- Strong insurer and TPA relationship-management skills.
- Excellent escalation management, negotiation, and problem-solving ability.
- Excellent communication skills and a customer-centric approach.
- Strong analytical and MIS skills.
- Ability to manage high-pressure, time-sensitive situations.
- Strong team leadership and people-management skills.

Why Join Us

You'll play a central role in our mission: ensuring every customer receives timely, transparent, and effective support when they need to use their health insurance the most.

📌 Claims Head – Health Insurance (Mumbai)
🏢 ConsultBae India Private
📍 Mumbai