Team Member - Cashless Claims

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

BusinessFinancial Service – HO

UnitAditya Birla Health Insurance Company Ltd

LocationThane

Poornata Position Number of the job Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)Assistant/Deputy Manager - ClaimsReports to: Poornata Position TitleManager/ Sr. Manager

FunctionServices OperationsReports to: Function Services Operations

DepartmentClaimsReports to: Department Claims

Designation of the Employee Assistant/Deputy ManagerDesignation of the Manager Manager/ Sr. Manager

Date of writing/updation of JD08.01.2024

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.

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

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

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)

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 submissionDo cursory/sanity checks before submission

Closure of audit observations

Trainings to the partner claim processors regarding policy T&C’s, Time management, DelegationStrong 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 & monitoringDaily intimation reportsMonthly MIS check - For TATOPD 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 emptyFuture date of admission should not be mentioned.Date of discharge < Date of AdmissionPolicy start date should not be blankPolicy end date should not be blankPolicy end date < Policy start datePolicy start date > Date of IntimationDate of Admission should be falling within Policy periodPaid amt>Claimed AmtPaid date Paid amt>SI Remarks

MVP implementations with OPD partners

Coordinating with Partner leadership teams /tech teams for MVP implementations viz;FWA triggers implemented in the system (automated)Automated ICD 10 coded data is needed.In health check-ups utilization should be driven towards home collection instead of hospitals.FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.Real time client Dashboard for client reviews.ABHI to be given system access for claim approvalCommunication letters in ABHI formatReports and Payment voucher in ABHI format (automated)All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)Query management – under deficiency option should be availableMedicos to process OPD claimsData digitization and automated reports to be availableAPI integrationsLimits and Sublimits to be defined in the partner system to ensure no over utilizationPortal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilization up to opted SICashless - Portal access end to endClaim Outstanding report (Daily MIS) to be sharedSymptom linking prior to slot booking for consultations Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

NA

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

Internal (MIS Team)

Ongoing

To coordinate and collate the data requirement. Coordinate with MIS template for processing payments of the partner

External

External Partners (Service providers)

As and when required

To decide on claims, reconsideration claims and claims beyond the authority of the Partner processing team, developments/ enhancements.

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 HolderReports to – Manager

Name

Signature (needed for the hard copy)