Job Title: General Manager – Mediclaim (Network Hospital Coordination)
Department: Insurance / TPA / Corporate Relations
Reporting To: Director / COO / Head – Operations
Location: Head Office with travel to network hospitals
Role Summary
The General Manager – Mediclaim is responsible for overseeing end-to-end coordination between the organization and all empanelled network hospitals. The role ensures smooth cashless claim processing, adherence to insurance protocols, strong hospital relationships, and efficient resolution of escalations, while maintaining compliance and service excellence.
Key Responsibilities1. Network Hospital Management
- Develop, maintain, and strengthen relationships with all empanelled hospitals.
- Oversee onboarding, empanelment, and periodic evaluation of network hospitals.
- Ensure hospitals comply with agreed service standards, pricing, and documentation protocols.
- Conduct regular audits and performance reviews of network hospitals.
2. Mediclaim & Cashless Coordination
- Supervise the end-to-end cashless claim process across all hospitals.
- Ensure timely pre-authorization, approvals, and claim settlements.
- Monitor TAT (Turnaround Time) for claim processing and reduce delays.
- Coordinate with TPAs, insurers, and hospital billing departments.
3. Escalation & Issue Resolution
- Act as the primary escalation point for complex or high-value claims.
- Resolve disputes related to billing, claim rejections, or policy interpretation.
- Ensure patient-centric solutions while safeguarding organizational interests.
4. Compliance & Documentation
- Ensure adherence to IRDAI guidelines, insurance policies, and internal SOPs.
- Monitor documentation accuracy and completeness for all claims.
- Implement fraud detection and prevention measures.
5. Team Leadership & Training
- Lead and manage the mediclaim coordination team across locations.
- Conduct regular training sessions for hospital coordinators and internal staff.
- Set performance targets and review team productivity.
6. Data Analysis & Reporting
- Track KPIs such as claim ratios, approval rates, rejection rates, and TAT.
- Prepare MIS reports for senior management.
- Identify trends and recommend process improvements.
7. Stakeholder Management
- Liaise with insurance companies, TPAs, corporate clients, and hospital administrators.
- Participate in contract negotiations and renewals with network hospitals.
- Ensure high levels of satisfaction among patients, hospitals, and insurers.
Key Performance Indicators (KPIs)
- Claim processing turnaround time (TAT)
- Cashless approval rate
- Claim rejection and query rates
- Network hospital satisfaction scores
- Compliance and audit outcomes
- Escalation resolution time
Qualifications & Experience
- Bachelor’s degree in Healthcare Administration / Business Administration / Life Sciences (Master’s preferred).
- 10–15 years of experience in mediclaim, insurance, or hospital operations.
- Strong exposure to TPA operations and network hospital management.
Required Skills
- In-depth knowledge of health insurance and cashless claim processes
- Strong leadership and team management skills
- Excellent negotiation and conflict resolution abilities
- Analytical and decision-making skills
- Effective communication and stakeholder management
- Familiarity with hospital billing systems and insurance software
Working Conditions
- Frequent travel to network hospitals
- Availability for handling escalations beyond regular working hours
Additional Expectations
- Maintain confidentiality and ethical standards
- Ensure patient-centric and service-oriented approach
- Drive continuous improvement in claim management processes
Pay: ₹90,000.00 - ₹100,000.00 per month
Benefits:
Work Location: In person
