TM-Ops Claim Professional

Job Purpose

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.

Dimensions

• Business Workforce Number: On Roll 6000+
• Business Workforce Number: Offroll/ Part time 4000+
• Unit Workforce Number: On Roll 6000
• Unit Workforce Number: Offroll/ Part time 4000+
• Function Workforce Number: On Roll 800
• Function Workforce Number: Offroll/ Part time 279
• Department Workforce Number: On Roll 69
• Department Workforce Number: Offroll/ Part time 66
• Other Quantitative and Important Parameters for the job: Budgets/ Volumes/ No. of Products/ Geography/ Markets/ Customers or any other parameter

Location

Thane

Job Context / Major Challenges

Major Challenges: To ensure quality in the claim process and audit, managing TAT as per agreed SLA.

Key Result Areas

• 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.
• DOA should not be empty
  1. DOA should not be empty
  2. Future date of admission should not be mentioned.
  3. Date of discharge
  4. Policy start date should not be blank
  5. Policy end date should not be blank
  6. Policy end date
  7. Policy start date > Date of Intimation
  8. Date of Admission should be falling within Policy period
  9. Paid amt > Claimed Amt
  10. Paid date
  11. Paid amt > SI Remarks
• MVP implementations with OPD partners
  • Coordinating with Partner leadership teams /tech teams for MVP implementations viz;
  1. FWA triggers implemented in the system (automated)
  2. Automated ICD 10 coded data is needed.
  3. In health checkups 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

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.