DM-Ops Claim Professional

Job Purpose

The Medical Claims Processor PreAuth is responsible for the accurate and timely assessment, processing, and authorization of cashless hospitalization requests in accordance with policy terms, medical guidelines, and company procedures. The role ensures adherence to service level agreements (SLAs), quality standards, and regulatory requirements while delivering an excellent customer experience.

Dimensions

• Business: Ficial Service HO
• Unit: Aditya Birla Health Insurance Company Ltd
• Location: Thane
• 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
• Department: Claims
• Reports to: Department: Team Lead Claims
• Designation of the Employee: Assistant/Deputy Manager/ Manager
• Designation of the Manager: Manager/ Sr. Manager/ DCM/ CM
• Date of writing/updation of JD: 08.01.2024

Job Context Major Challenges

The Medical Claims Processor PreAuth operates in a highvolume, timesensitive environment where prompt and accurate claim decisions directly impact customer experience and healthcare service delivery. The role requires evaluation of preauthorization requests received from hospitals by reviewing policy coverage, medical documentation, treatment necessity, exclusions, waiting periods, and claim eligibility while adhering to defined turnaround times (TATs) and quality standards.

The key challenge is balancing speed with accuracy, as authorization decisions must be made within stringent SLA timelines without compromising on quality, compliance, or risk management. The incumbent is required to coordinate with hospitals, medical teams, customers, and internal stakeholders to obtain complete and

The role also involves handling reimbursement/Pre Auth/ Retail/Group medical cases, incomplete documentation, treatment justification reviews, policy interpretation issues, and escalations from hospitals or customers. Ensuring compliance with organizational policies, regulatory requirements, fraud control measures, and audit standards while maintaining productivity and service quality is a critical aspect of the position.

• Managing high volumes of all types of claims (retail/group) requests within defined TATs.
• Ensuring accurate claim decisions while minimizing operational and fical risk.
• Reviewing all levels of medical cases and treatment protocols.
• Handling incomplete or inadequate documentation from hospitals.
• Managing customer and hospital expectations during urgent hospitalisation cases.
• Identifying potential fraud, abuse, and policy misuse.
• Maintaining quality scores, audit compliance, and productivity targets simultaneously.
• Coordinating effectively with medical experts, hospitals, TPAs, and internal functions for timely claim resolution.
• Keeping abreast of policy updates, medical advancements, and regulatory changes impacting claim adjudication.

Key Result Areas

Key Result Areas (Max 1325 Characters)

Supporting Actions (Max 1325 Characters)

Accurate and timely submission of periodic and adhoc reports related to Claims

• Develop, Implement shortcuts, formulae on excel, using alternative tools/methods for timely submission
• Do cursory/sanity checks before submission

Closure of audit observations

• Trainings to the partner claim processors regarding policy TC s, Time management, Delegation
• Strong 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;

1. LDR report monitoring
2. Daily intimation reports
3. Monthly MIS check For TAT
4. OPD FWA Savings data

DN monitoring for check pts

• Debit note supervision for all the payments from TPA s OPD Partners Viz.

1. DOA should not be empty
2. Future date of admission should not be mentioned

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.