Key Responsibilities

Claims Operations Management

- Manage end-to-end reimbursement claim processing and settlement activities.
- Ensure claims are adjudicated in line with policy terms, medical underwriting guidelines, and company procedures.
- Monitor claim processing TATs and drive timely closure of cases.
- Review high-value, complex, and exception claims before settlement.

Team Leadership

- Lead, mentor, and develop a team of claim assessors and executives.
- Drive productivity, quality, and compliance within the team.
- Conduct regular performance reviews and capability-building initiatives.
- Ensure optimum workforce planning and resource utilization.

Quality & Compliance

- Ensure adherence to IRDAI regulations, internal controls, and audit requirements.
- Monitor claim quality scores and implement corrective actions.
- Prepare teams for internal, statutory, and regulatory audits.
- Maintain process documentation and ensure SOP compliance.

Fraud Risk Management

- Identify claim leakage trends and suspicious claim patterns.
- Coordinate with investigation teams for fraudulent or suspicious claims.
- Recommend process improvements to minimize fraud and operational risks.

Stakeholder Management

- Collaborate with hospitals, TPAs, service providers, underwriting, legal, and customer service teams.
- Resolve escalated customer grievances and complex claim-related issues.
- Build strong relationships with internal and external stakeholders.





Process Improvement & Analytics

- Analyze claim trends, repudiation ratios, and operational performance metrics.
- Drive automation and process enhancement initiatives.
- Prepare MIS, dashboards, and management reports for senior leadership.
- Recommend strategies for cost optimization and improved customer experience.

Eligibility Criteria

- Graduate in any discipline.
- Preferred qualifications: BAMS, BHMS, MBBS,
- 7-12 years of experience in Health Claims/Reimbursement Operations within General Insurance, Health Insurance, or TPA organizations.
- Minimum 2-3 years of team-handling experience in a managerial capacity.

Required Competencies

- Robust knowledge of health insurance claims and reimbursement processes.
- Sound understanding of medical terminology, treatment protocols, and hospital billing.
- Leadership and people management skills.
- Analytical and problem-solving ability.
- Decision-making and risk assessment capability.
- Stakeholder and customer management skills.
- Excellent communication and presentation skills.
- Proficiency in claims management systems and MS Office.

Key Performance Indicators (KPIs)

- Claims Settlement TAT
- Claims Accuracy Rate
- Quality Audit Score
- Team Productivity
- Customer Satisfaction Score (CSAT)
- Grievance Resolution Efficiency
- Fraud Detection & Prevention Effectiveness
- Regulatory & Audit Compliance
- Cost and Claim Leakage Control

📌 Vertical Head Health Claims Reimbursement (Pune)
🏢 Bajaj General Insurance
📍 Pune