DM-Claims

Position: DM-Claims )
Job Description
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
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

Reports to:

Department
Claims
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)

The purpose of this role includes ensuring coordination with the Service provider partner team for timely settlement of Travel and OPD claims. Candidate should be able to do regular medical and technical audits of the claims approved for settlement by the partner and should be able to maintain the MIS/Reports related to claims.

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:

Writethe 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
Strong 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 Policy start date
Policy start date Date of Intimation
Date of Admission should be falling within Policy period
Paid amt Claimed Amt
Paid date DOA
Paid amt 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)
2. Automated ICD 10 coded data is needed.
3. In health check-ups utilization should be driven towards home collection instead of hospitals.
4. FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)
5. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.
6. Real time client Dashboard for client reviews.
7. ABHI to be given system…