Head - Claims - Health Insurance

Client Profile :

Our client is an established, reputed, leading, rapidly growing, very-well funded Health Insurance organisation. They have multiple plroduct categories. Our clients offer customers a transparent, stress-free process of buying services and an easy seamless servicing platform. Using data, analytics and technology, the platform enables customers to access optimal product offerings. Response of consumers has been extremely encouraging. Our clients are growing at a rapid pace. Our clients seek to recruit young, dynamic & experienced Health Claims professionals to lead the claims operations of the Health Insurance.

What can you expect: Autonomy in decision making, Exciting environment while doing industry first experiments/ innovations, Highly meritocratic set up - High growth trajectory when you do well, Collaborative people and mission first approach to problem solving

Interviews are scheduled mid-June and the position is expected to be closed by end-June.

We have the following vacancy:

1.Head-Health Claims We are seeking a professional who will run key the function independently and lead a team.

KRAs

a) Driving health claims strategy formulation and setting up of processes for the function

b) Leading a team handling claims, customer queries & complaints, claim notification & registration, reserving of claims, coordination, etc.

c) Staying up-to-date on amendments and provisions in health insurance regulations & implementing changes in claims processes to ensure compliance.

d) TPA/OSP (overseas service provider) evaluation, empanelment & driving performance management strategies.

e) Hospital & providers network management

f) Formulating & ensuring near paperless claims settlement with superior TAT & customer experience.

g) Supervision and medical review of high loss health indemnity, critical-illness claims.

h) Analyzing incurred claims ratio, review of portfolio and taking proactive action for loss control measures.

i) Interacting, co-ordination & collaboration with product, actuarial/ U/W team for review/follow up and finalizing underwriting guidelines for all types of health products.

j) Interacting, co-ordination & collaboration with technology teams for design & development of health claims systems that support near paperless claims management strategies.

k) Contributing to the growth of the business through regular interactions, support with relevant stakeholders.

l) Designing & implementing performance management parameters (entire portfolio). Medical data analytics, reporting for the stakeholders like (department head, management committee, regulator, IIB etc.) on defined intervals.

m) Developing & implementing health claim fraud prevention & loss mitigation framework.

n) Training & development to medical processors. Identifying key learnings, gaps, and opportunities for individuals to develop the team.

o) Building & maintaining a relationship with external service partners including but not limited to Investigators, OSP, Hospitals,

- Candidate Profile Preferably M.B.B.S/B.A.M.S/B.H.M.S with 715 years Insurance Industry/OSP/Wellness experience. (or Graduates in any discipline with insurance qualifications).

- Must have experience in TPA empanelment and management with exposure in health claims systems. Basic knowledge of medical underwriting & health claims administration.

- Design,implement & monitor health claims fraud prevention & loss mitigation framework. Results-oriented professional with strategic, administrative and operations experience in health insurance/ health care/ wellness domain with a strong understanding of health.

- Insurance applications, workflow, including but not limited to claims, cost containment strategies and implementation.

- Experience in product design, underwriting exposure medical and domain.

- Experience in accident & health claims adjudication, claims operations, hospital administration with provider network management abilities. Excellent leadership and interpersonal skills, team player and can work & communicate effectively with all levels of an organization.

Skills :

- Monitoring & assessing performance, Leadership & negotiation, High on customer service orientation, Judgment & decision making. Effective communication. Collaboration, Team management