TM-Ops-Claims(Thane )

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: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 updatedKey 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 submissionClosure 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 vizLDR 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 DOAPaid amt SI Remarks MVP implementations with OPD partners Coordinating with Partner leadership teams /tech teams for MVP implementations viz1. 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 access for claim approval 8. Communication letters in ABHI format 9. Reports and Payment voucher in ABHI format (automated) 10. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields) 11. Query management - under deficiency option should be available 12. Medicos to process OPD claims 13. Data digitization and automated reports to be available 14. API integrations 15. Limits and Sublimits to be defined in the partner system to ensure no over utilization 16. Portal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilization up to .