Lead - Claims

Role purpose

This position is responsible for leading the Claims MIS and reporting function. The role ensures that regulatory and ad hoc claims reports are prepared accurately and on time, supports audit activity across internal and external reviews, maintains the claims register, and drives improvements through automation, analytics, and better process controls.

The role also acts as a key data support partner and coordinates closely with teams across sales, finance, claims, and actuarial functions.

Scope and scale

The business workforce number for this role is 6. The job also carries responsibility for preparing and publishing Claims MIS.

Key responsibilities

The role covers regulatory reporting, audit management, claims analytics, dashboard publishing, and cross-functional coordination. It includes periodic data submission, query handling, trend analysis, and ensuring that claim-related reports are reliable and delivered within required timelines.

Regulatory reporting and compliance

Prepare accurate periodic and ad hoc submissions related to claims for the regulatory authority and GI Council. Manage monthly, quarterly, and annual data submissions, respond to queries, and help ensure there are no compliance breaches related to claims turnaround times or reporting timelines.

Audit ownership

Take full ownership of claims-related audits, including IRDA, internal, statutory, concurrent, and retrospective reviews. Support the closure of observations, coordinate follow-ups, and ensure that all required information is shared correctly and on time.

Dashboards and analytics

Build and publish daily, weekly, and monthly dashboards covering claims intimations, TAT, NPS, settlement ratio, average claim size, productivity, pendency, and digital metrics. Analyse trends in claims performance, identify risks or fraud indicators, and share insights with relevant stakeholders for action.

Coordination and stakeholder management

Work closely with internal teams such as sales, finance, actuarial, underwriting, FWA, customer care, and claims teams, along with external stakeholders when needed. The role requires strong collaboration to gather inputs, validate data, resolve queries, and support reporting requirements across forums such as committee reviews and operational meetings.

Challenges in the role

The health insurance market is highly competitive, with multiple private players and a large share of renewals retained by existing insurers. This creates pressure to win and retain business through better solutions, broader reach, and efficient operations.

The role must also deal with changing customer expectations, increasing medical costs, evolving healthcare needs, and the need to support a digitally enabled, paperless operating model. A major challenge is delivering MIS, regulatory submissions, and analysis consistently despite system and infrastructure limitations, often by using manual workarounds where required.

Direct report purposes

Claims Daily Dashboard: Responsible for managing and publishing daily, weekly, and monthly dashboards covering claims intimations, TAT, NPS, settlement ratio, average claim size, productivity, pendency, and digital metrics.

Claims MIS Regulatory Reporting: Responsible for timely and accurate regulatory submissions, ad hoc reporting, and inputs for forums such as the Policyholder’s Protection Committee and Risk Management Committee.

Claims MIS Analysis: Focused on trend identification, fraud indicators, TPA performance monitoring, system development support, UAT, portfolio analysis, and root-cause analysis for claims MIS and compliance.

Key relationships

Internal: Underwriting, Group Operations, Actuarial, Finance, Planning, Legal, Compliance, Claims Committee, and Claims Review Committee. These interactions support claim inputs, settled and outstanding MIS, budget approvals, legal and compliance guidance, committee decisions, forecast support, and query resolution.

External: Select advisors, brokers, key relationships, and affinity partners. These contacts are used to publish claims MIS such as paid, outstanding, repudiated, and ageing information.

Other job information

The role is based in Thane, Maharashtra, India, and is a full-time onsite position. No compensation, vacancies, start date, application deadline, or eligibility details were provided in the source.

Organizational notes

The source mentions sign-off requirements for the job holder and the reporting manager, including name and signature fields for hard-copy records.