AM-Ops Claims

Role overview

This position is part of the claims operations function at Aditya Birla Health Insurance Company Ltd in Thane. The role focuses on coordinating with a service-provider partner team to ensure Travel and OPD claims are settled on time, while also carrying out regular medical and technical checks on approved claims and maintaining claims MIS and reports.

Role details

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane, Maharashtra, India

Function: Services Operations

Department: Claims

Designation: Assistant/Deputy Manager

Manager designation: Manager / Sr. Manager

Date of JD update: 08.01.2024

Job purpose

The role exists to help ensure that Travel and OPD claims are processed and settled within agreed timelines, in coordination with the partner service team. It also requires auditing approved claims for medical and technical accuracy and keeping claims-related MIS and reporting up to date.

Scope and dimensions

Business workforce: On-roll 6000+, off-roll/part-time 4000+

Unit workforce: On-roll 6000, off-roll/part-time 4000+

Function workforce: On-roll 800, off-roll/part-time 279

Department workforce: On-roll 69, off-roll/part-time 66

No other budgets, volumes, product counts, geography, or customer-scale parameters were specified.

Job context and key challenge

A major challenge in this role is maintaining claim quality and audit standards while also meeting turnaround times in line with the agreed SLA.

Key responsibilities

• Prepare and share periodic as well as ad hoc claims reports accurately and on time.
• Build time-saving Excel shortcuts, formulas, and other practical tools to speed up reporting.
• Run basic checks and validation steps before any report is sent out.
• Close audit observations by working with partner claim processors and reinforcing policy terms, time discipline, and proper delegation.
• Coordinate closely with internal and external stakeholders for monthly, quarterly, and annual data submissions.
• Manage claims data, MIS, and reporting in partnership with external data teams.
• Track LDR reports, daily intimation reports, monthly TAT MIS, and OPD FWA savings data.
• Monitor debit notes and verify payment-related checkpoints for TPA and OPD partner payouts.
• Check claim data for control points such as missing DOA, invalid admission dates, mismatched admission and discharge dates, blank policy dates, incorrect policy timelines, admission outside policy period, and payment values exceeding claim values or policy remarks.
• Support MVP rollout initiatives with OPD partners and coordinate with partner leadership and tech teams.
• Help implement automation and process enhancements such as FWA triggers, ICD-10-coded data capture, home collection preference for health checks, automated claim adjudication rules, real-time client dashboards, system access for ABHI claim approval, ABHI-format letters and vouchers, complete audit-ready report fields, query management, medicos-led OPD processing, digitized data and automated reports, API integrations, sub-limit controls, wallet and utilization validations, full cashless portal access, daily outstanding MIS, and symptom-based booking flow.

Stakeholder relationships

Internal: Work on an ongoing basis with the MIS team to gather data requirements and align MIS templates used for partner payment processing.

External: Interact with service providers and other external partners as needed to decide on claims, reconsideration requests, claims beyond partner processing authority, and system/process enhancements.

Organizational notes

Job holder and manager sign-off details were mentioned for record maintenance, with a hard copy of the JD to be retained in organizational records.

Additional notes

No direct reports were listed for this role. The source document did not specify salary, stipend, number of openings, start date, or application deadline.

The document also noted that the manager and job holder names/signatures are required on the hard copy of the JD.