GM - Health Claims

Responsible to manage overall health and accident claims processes across India.
Will also be responsible to manage various external stakeholders like all TPAs with
various external stakeholders like all TPAs with whom we have engaged to service our
policies, hospital relations, etc. Will also manage Health reporting to IRDAI and IIB. Will be
responsible for handling a team size of 4 to 5 members initially.

Duties And Responsibilities

Responsible for complete end to end processing, adjudication and payment of
health and accident claims
Responsible for claim reporting and claims MIS
Manage all empaneled TPAs and get them to adhere to the defined SOPs
Adherence to defined claims SOP, TAT and compliance to IRDAI guidelines
Responsible for claims system development and improvements
Responsible to manage a team for network empanelment and design strategies for availing best in class discounts and services from the empaneled hospitals
Responsible for overall claims cost and should be able to manage the cost escalation to minimal
Should be able to create a framework to detect fraud and leakages and manage overall cost escalation
Monitor all aspects of the service delivery in accordance with the contractual commitments and SLA commitments to different stakeholders. Needs to ensure that the delivery is done in accordance with the same.
Monitor Productivity in Claims processing and Cashless processing.
Monitor customer complaints, trend and timely resolution
Monitor customer queries on call center and review the SOPs followed and suggest better process to smoothen customer experience.
Manage Insurance Audits and implement actions to avoid future findings.
Manage team and review processes, team structure and ensure alignment.
Responsible to provide managerial guidance to the team and will act as a point of escalations to address concerns and provide timely resolution.

Post graduate with relevant experience in Health Claims management

Strong proficiency in all areas of Health insurance claims

High level of accuracy with claim financials:

Advanced understanding of Claim Best Practices and Business Analytics

Exceptional negotiation skills and resources that will influence team results

Strong business acumen and understanding of the fundamental components of Claims, Underwriting, agency relationships, industry strategies and trends
Extensive knowledge of insurance contracts, investigation techniques, legal requirements and insurance regulations

Exceptional oral, written, and presentation skills that positively influence a wide audience within and outside the Claim department