Responsible for all Claims deliverables by managing the Claims function for the assigned business.
The role includes managing the assigned specialized business handling of any one or more of the following activities:
Claims – Processing & Monitoring of Indemnity and Fixed Benefit Claims & In-house & TPA processed claims.Products Development – Providing Support on various claims related aspect to Product development team.System Development – Key Role in development of In-house Claim Process System, responsible for System UAT.TPA Management – Monitoring Group Claim Process, QC & TAT. Responsible for TPA performance measurement, Portfolio Analysis. Doing Root Cause Analysis of portfolio performance, Claims analysis, Monitor Claims team performance metrics.Address complaints/queries from Customers, Intermediaries, Sales, other departments within the Company, Audit Training / BCP / Risk, Review, MIS / Compliance.
Job Context: /Job Challenges:
Health insurance is a new and complex business with a combination of health and wellness initiatives. The business model requires the team to understand and deliver superior customer experience along with being cost effective and also having a scalable business model.
The unique challenges of the business require close review and management of Underwriting and Claims to deliver the purpose of the business effectively.Distribution: How we create specific distribution models to penetrate different market segments remains a challenge. Motivation to channel partners to place business with the co. Activate and manage agent based distribution channel across the countryLong term and short term strategic plans to increase the market share and profitability in line with the company’s business objectives. Identifying new segments, structure offerings, and value enhancers apart from creating differentiators’ remains a big challenge for the company’s growth. Meeting varied client’s expectation in terms of solutions, pricing and operational support remains a challenge.System development & UAT, Claims: Indemnity & Fixed benefit products (Health: - Retail & Corporate, PA, Travel, Hospital Cash, Critical Illnesses).Knowledge of Claims processes: Indemnity (Cashless, Reimbursement), Fixed Benefit Products.Knowledge of Claims MIS: Indemnity & Fixed benefit products.Understanding of Claims systems (process flow & System fields) – Health Indemnity & Fixed Benefits.Experience in measurement of performance (TAT, accuracy in claims adjudication).Expectations management of the Claims team.TAT & expectations management for specialized business handling.Ensure uniformity in quality & maintain TATs of Claims decisions.
KRA (Accountabilities) (Max 1325 Characters)
Supporting Actions (Max 1325 Characters)
KRA1
IT Systems Development
System development, UAT Indemnity & Fixed benefit products (Claims)
KRA2
Monitor Claims Team Performance metrics
Monitor Claims transactions, authority limits, TATs
Appropriate & timely resolution of escalations
Measure Claims decisions: Quality & TAT (in House & TPA processed Claims)
Review of o/s Claims
KRA3
Recommend empowerment for Claims Officers
Audit
Training
KRA4
Review the Claims guidelines v/s competition
Analyze business trends, recommend changes if any.
Perform cost benefit analysis.
