Lead - Claims (Thane)

Job Summary

The purpose of this role is to plan, establish and supervise the MIS function of Claims. This includes ensuring accurate and timely submission of periodic and adhoc reports related to Claims to the Regulatory Authority, handling Audits (IRDA, internal audits and other audits), preparing the claims register, bring in process improvements, automation, publishing analytical reports / Claims MIS and daily dashboard.

The purpose involves Data Support and interdepartment coordination with all stakeholders including sales, fice, internal claims and actuary teams.

Dimensions

• Business Workforce Number (Max 254 Characters): 6
• Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter
• Prepare and Publish Claims MIS

Responsibilities

• Regulatory Submissions: Accurate and timely submission of periodic and adhoc reports related to Claims to the Regulatory Authority/GI Council
• Handling Audits (IRDA, internal audits)
• Complete ownership of handling all audits in the Claims function IRDA, Internal, Statutory, Concurrent and Retrospective
• Data submission/query response/adhoc reports to IRDA/GI Council
• Ensure proper closure of audit observations
• Publish Dashboards
• Claims TATs: Cashless, Reimbursement in house TPA periodically
• Analytics Claims trends and Apprise/Alert the relevant stakeholders
• Publish Daily/weekly/monthly dashboards related to Claims Intimations, TAT, NPS, Settlement Ratio, Average Claim size, Productivity, Pendency, Digital metrics
• Monthly / Quarterly / Annual Data submission
• Coordination Interdepartmental/within the department
• With internal/external stakeholders including Sales, Fice, Actuary, Underwriting, FWA Internal claims team Cashless, Reimbursement, Grievances, Group, Customer Care Team

Metrics

• Metric: PBT before Holdco expenses
• Units: Rs Mn
• FY18B: 1,709
• FY19: 2,021
• FY20: 1,628

Job Context: Major Challenges

About the Health Insurance Industry

While the current market sees more than 15 nonlife players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 10,000 Crs sees close to 85 % of the business renewing with the existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market to approximately 1500 odd Crs. With the SME and the startups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardized solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them.

Market Opportunities With the advent of medical advancements, lifestyle changes, change in Indian socioeconomic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

Challenges

• To ensure to publish MIS, Regulatory Data submission, Analysis on periodic basis with effective controls built in and allied activities by overcoming system and infrastructure constraints.
• To identify trends, alert and suggest strategies towards risk/fraud mitigation strategies and policies within the framework of Compliance/ Group s Policies.
• To identify and prevent regulatory breach of Claims TAT s, and timely data submission by overcoming challenges related to systems and infrastructure, using manual methods where required.

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