TataAIG - Manager - Health Claims

As Manager - Health Claims, you will play a critical role in adjudicating and managing health insurance claims by integrating clinical knowledge with data-driven decision-making. You will ensure claims are processed accurately, within regulatory and company guidelines, while maintaining operational excellence and customer trust.

This position involves a blend of medical expertise, analytical judgment, and process governance, supported by Tata AIGs advanced claims management systems.

Key Responsibilities

1. Claims Assessment & Adjudication

- Analyze medical documents, discharge summaries, diagnostic reports, and treatment details to ensure alignment with policy terms and conditions.

- Apply evidence-based medical judgment to support approval or rejection decisions.

- Identify inconsistencies or anomalies in claims and escalate for further medical or fraud review.

2. Policy & Regulatory Compliance

- Interpret and apply policy wordings, inclusions/exclusions, and regulatory guidelines during claims processing.

- Ensure all adjudications comply with IRDAI standards, internal audit norms, and Tata AIGs governance policies.

- Maintain up-to-date understanding of healthcare regulations, clinical protocols, and insurance compliance frameworks.

3. Process Excellence & Automation

- Leverage Tata AIGs claims management system (CMS) and digital tools for efficient case tracking and workflow automation.

- Support the integration of AI/ML-based decision engines that assist in predictive analysis and fraud detection.

- Contribute to the optimization of claims turnaround times (TATs) and enhancement of processing accuracy through data-driven insights.

4. Quality Review & Auditing

- Conduct peer reviews and quality checks on processed claim files to ensure accuracy and adherence to medical and procedural standards.

- Collaborate with internal audit and compliance teams to drive zero-defect processing.

- Support internal training programs on claims quality improvement and knowledge sharing.

5. Grievance & Escalation Management

- Manage customer grievances related to health claims in coordination with service and legal teams.

- Analyze root causes of escalations and recommend process-level improvements to minimize recurrence.

- Ensure all grievance resolutions meet defined TATs and service-level benchmarks.

6. Fraud Detection & Risk Mitigation

- Identify patterns indicative of fraudulent or inflated claims through analytical review of cases.

- Collaborate with the Special Investigation Team (SIT) to validate clinical and billing authenticity.

- Contribute to building a database of suspicious claim behaviors and help strengthen preventive controls.

Qualifications & Experience

Education: BAMS or BHMS (Mandatory)

Experience:

- Freshers and early-career professionals are encouraged to apply.

- Prior experience in clinical practice, Third-Party Administrators (TPA), or health insurance claim processing will be advantageous.

Technical Competencies:

- Familiarity with claims management or hospital information systems (HIS).

- Basic understanding of Excel-based reporting, MIS tools, and data validation workflows.

- Exposure to digital health platforms or electronic medical records (EMR) will be a plus.