Designation: Location: India Maharashtra Thane - GCorp

Organization: Financial Services : Basic Details : Fill the required information about business, unit, location, position, reports to position and date of updation of JD : **-

- Business**

**-

- Financial Service - HO**

**-

- Unit**

**-

- Aditya Birla Health Insurance Company Ltd**

**-

- Location**

**-

- Thane**

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- Poornata Position Number of the job**

**-

- Reports to: Poornata Position Number**

**-

- Poornata Position Title of the job (30 characters max)**
- Assistant/Deputy Manager - Claims

**-

- Reports to: Poornata Position Title**
- Manager/ Sr. Manager

**-

- Function**
- Services Operations

**-

- Reports to: Function**
- Services Operations

**-

- Department**
- Claims

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- Reports to: Department**
- Claims

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- Designation of the Employee**
- Assistant/Deputy Manager

**-

- Designation of the Manager**
- Manager/ Sr. Manager

**-

- Date of writing/updation of JD**
- 08.01.2024

1) Job Purpose : Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters) : **-

- 2) Dimensions**: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.
- Business Workforce Number
- (Max 254 Characters)
- On Roll - 6000+

Offroll/ Part time - 4000+

- Unit Workforce Number
- (Max 254 Characters)
- On Roll - 6000

Offroll/ Part time - 4000+

- Function Workforce Number
- (Max 254 Characters)
- On Roll - 800

Offroll/ Part time - 279

- Department Workforce Number
- (Max 254 Characters)
- On Roll - 69

Offroll/ Part time - 66

- Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

- 3) Job Context & Major Challenges:



Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters) :

- To ensure Quality in the claim process and audit, managing TAT as per agreed SLA

- 4) Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)- Maximum 10 KRAs can be updated : -

- Key Result Areas ( Max 1325 Characters)
- Supporting Actions (Max 1325 Characters)
- Accurate and timely submission of periodic and ad-hoc reports related to Claims
- Develop, Implement shortcuts, formulae on excel, using alternative tools/methods for timely submission
- Do cursory/sanity checks before submission
- Closure of audit observations
- Trainings to the partner claim processors regarding policy T&C;’s, Time management, Delegation
- Solid coordination skills with other departments, sharp and on the spot thinking, proactive approach, soft skills, excel skills etc.
- Monthly / Quarterly / Annual Data submission
- Work closely with related stake holders (internal and external)
- Working on DATA / MIS
- Work closely with data teams of external stake holder for reports viz;
- LDR report & monitoring
- Daily intimation reports
- Monthly MIS check - For TAT
- OPD FWA Savings data
- DN monitoring for check pts




- Debit note supervision for all the payments from TPA’s & OPD Partners Viz.
- DOA should not be empty
- Future date of admission should not be mentioned.
- Date of discharge < Date of Admission
- Policy start date should not be blank
- Policy end date should not be blank
- Policy end date Date of Intimation
- Date of Admission should be falling within Policy period
- Paid amt>Claimed Amt
- Paid date SI Remarks
- MVP implementations with OPD partners
- Coordinating with Partner leadership teams /tech teams for MVP implementations viz;
1. FWA triggers implemented in the system (automated)

1. Automated ICD 10 coded data is needed.

2. In health check-ups utilization should be driven towards home collection instead of hospitals.

3. FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)

4. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.

5. Real time client Dashboard for client reviews.

6. ABHI to be given system access for claim approval

7. Communication letters in ABHI format

8. Reports and Payment voucher in ABHI format (automated)

9. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)

10. Query management - under deficiency option should be available

11. Medicos to process OPD claims

12. Data digitization and automated reports to be available

13. API integrations

14. Limits and Sublimits to be defined in the partner system to ensure no over utilization

15. Portal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilization up to opted SI

16. Cashless - Portal access end to end

📌 Team Member - Cashless Claims (Maharashtra)
🏢 Aditya Birla Group
📍 Maharashtra