TL-Cashless Claims (Hyderabad)

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

Business

Health Insurance

Unit

Aditya Birla Health Insurance Company Ltd

Location

MBC, Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)

TM-Mrg-Claims-3-Thane

Reports to: Poornata Position Title

Head – Reimbursement/Cashless Claims

Function

Services Operations

Reports to: Function

Services Operations

Department

Ops - Claims

Reports to: Department

Ops – Claims

Designation of the Employee

Team Lead - Claims

Designation of the Manager

Associate VP

Date of writing/updation of JD

20 th July 2021

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

To role is required to manage Claims Payments of Indemnity & Fixed Benefit Claims; within specified TAT & as per IDRA Guidelines

• 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)

Unit Workforce Number

(Max 254 Characters)

Function Workforce Number

(Max 254 Characters)

Department Workforce Number

(Max 254 Characters)

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

Business KPI & TAT

• In House Processed Claims –
• Pre Auth Process - 2 hrs (Approval / Denial / Response / Query)
• Re-imbursement Claims – 5 working days
• Claims Processing TAT – 7 days
• Grievance Resolution – 15 working days
• Monitor & Maintain ACS as per Benchmark – Cashless / Re-imbursement / Combined
• Claim Approval & Denial basis the Claim Approval / Denial Authority Matrix defined
• TPA processed Claims –
• Pre Auth Approval - 30 mins
• Pre Auth & Re-imbursement Claims Denial
• QC & Claims Audit –
• QC of claims processed in In-House ABHI System
• Periodic Audit of Paid Claims processed by TPAs
• Claims System Development –
• Requirement Gathering, Support for System Development requirement
• 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)

About The Health Insurance Industry –

While the current market sees more than 15 non-life players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 10,000 Crs sees close to 85 % of the business renewing with the existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market to approximately 1500 odd Crs. With the SME and the start-ups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardized solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them.

Market Opportunities – With the advent of medical advancements, lifestyle changes, change in Indian socio-economic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

About The Aditya Birla Health Insurance –

Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016.

ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6th entrant in a category with well-established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of “Health Insurance for All”, a one of a kind proposition in India at the moment. This is a philosophy that is being built through every single consumer touch point and into every single backend process of the company to ensure a customer’s experience of our proposition is continuous and seamless.

ABHI’s unique offering to market includes proposition includes -

• A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
• A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1
• ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.
• ABHICL’s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.

Key Challenges for the role –

• Create, monitor and improve Innovative Claim Processes, SOPs, Protocols & implement the same for Claims Processed through In-house Team as well as Claims Processed through Partner TPAs
• Ensuring that the team members are up-to speed in a short time frame and enhancing their Skills by Periodic Functional & Product Training Programs
• System development & UAT, Claims: Indemnity & Fixed Benefit Products (Retail & Group)
• Expectations management of the Claims team & TAT & expectations management for specialized business handling.
• Claims decisions in adherence & compliance with the Claims guidelines, uniformity in decisions, and approval authority limits (In house and TPA claims)
• Periodic Portfolio analysis & Maintain a consistent service delivery to ensure client retention and satisfaction

Minimise Loss Ratio & Monitor the Profitability of Portfolio

• 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)

IT Systems Development

• System development, UAT Indemnity & Fixed benefit products (Claims)

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

Recommend empowerment for Claims Officers

• Audit
• Training

Review the Claims guidelines v/s competition

• Analyze business trends, recommend changes if any.
• Perform cost benefit analysis.
• Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

Sr. Executive – Claims

The purpose of this role is to promptly settle all legitimate claims/benefits falling within the authority limit and within the IRDA stipulated time

• Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type (Max 80 Characters) Frequency Nature (Max 1325 Characters)

Internal

New Business & Policy Administration

Legal/Compliance

Sales

IT

Underwriting

Internal Audit Team

Provider Management Team

Product Team / Actuary Team

Daily Basis

Need Based

Frequently

Need Based

Need Based

Need Based

Need Based

Need Based

Interaction & Escalation Resolution w.r.t. Policy Status, Policy Details, Endorsement details, etc.

Legal & compliance issue w.r.t to policies in Claims related disputes

Vendor Agreements & Claims SOP

Query Resolution, VIP Claims tracking, updation of Claims Status / Claim Payment Status, Support for Daily & Periodic MIS

Support for System Development / Enhancements

Identification & highlighting various bugs / issues observed during the claim process

Updating w.r.t policy & proposal form related queries raised during claim process

Internal / External Audit

Queries resolution / General enquiry, follow up Tri-partite agreement, sharing Cashless claim’s payment & deduction details on daily basis

New product development / launch related.

Development of Claims SOP & Processes as per product guidelines

Support for filling documents

External

Policyholders

Vendors

External auditors

Brokers

Partner TPAs

Need based

Need based

Need based

Need based

Daily Basis

Conveying decisions / Query Resolution

Queries resolution / General enquiry

Queries resolution / General enquiry

Conveying Decisions / Query Resolution.

For Various Claims Activities & Reports, Claims Payment, Claims Reserves & MIS

• Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)