Zonal Claims Administrator- ZOCA

Job Description Zonal Claims Administrator- ZOCA

Claims Processes

1. Each zone shall have a ZOCA responsible for claims functions at Zonal level and reporting into the Regional Claims Head.

2. ZOCA shall co-ordinate with Regional claims team and HO Claims to ensure that claims processing of Cashless and Reimbursement claims are smooth and effective.

3. Claims are processed within TAT and will coordinate in such a way that the Claims resolutions are quicker to ensure customer satisfaction.

4. Attend to any hurdles in full lifecycle of the claim.

5. Report and Resolve bottlenecks in upload of claims, processing and settlement of Reimbursement claims irrespective of source or collection of NEFT/ Payee / Nominee details

6. The position will not have any claims settlement authority, unless specifically given.

7. Shall be responsible for the quality & efficiency of uploading / ROD/ Billing at Zonal levels.

8. Shall attend to the complaints from agents and other marketing personnel, check the status of the claims, inform them about it, coordinate with Corporate team on any delayed claims, follow up coordinator/ query requirements etc . For this they shall use the Escalation matrix already laid down.

9. For issues in cashless claims they shall be in touch with Claims processing Drs

10. Work as an Early Warning system to avoid any bottlenecks that may be getting developed at local levels. This could be spread of local contagious infections like Dengue, resignation of critical personnel, hospitals over charging claimants etc.

11. Look out for potential High Loss ratio triggers and inform concerned higher ups for corrective steps.

12. Coordination with Zonal Grievance coordinators for speedy resolution of grievances related to claims.

13. Checking and confirming that various SMS / E mails from Claims dept are reaching the target customers by looking at random samples.

14. Shall check the efficacy of IT systems and if any deficiencies are noted at ground levels, suggestions may be provided to HO Claims.

15. They shall popularize the usage of Star Health App, among customers and VO / Atom app among Agents and SMs

16. Ensure that the reimbursement claims of OPD & Preventive Health Care ( PHC) & Pre approval Tests are settled at Zonal Office quickly and efficiently. As far as feasible encourage PHC in Cashless mode only.

17. Promotion of HHC , Telemedicine's , Wellness Others

Fraud Mitigation

1. ZOCAs shall watch out for any signs of Fraud, Waste and Abuse by Ptoviders, Marketing channels or customers and take corrective measures through appropriate reporting and follow up action.

2. Study and report on High ICR Branches/ SMs and Agents for any tendencies on fraud within employees.

3. Provide necessary support to HRM/FVR/ Vigilance officer / Fraud investigator

Administration

1. Shall be responsible for the overall functioning of the Claims team at Zonal level with upward and downward dissemination of relevant information.

2. The Branch Service Executives, Claims executives, Zonal Claim Co-ordinators shall report into ZOCA.

3. Shall be responsible for training, mentoring and development of Claims team members.

4. Responsible for Attendance and discipline within the team.

5. Periodic Branch Visit for marketing interactions and review of BSE function.

6. Organize reviews of High ICR branches with the help of Processing heads.

7. Co-ordinate with Training team for updation of product knowledge to team members and field feedback and updates.

8. Inter-departmental co-ordination and daily updates to Regional Claims Head.

9. Keep higher management informed about any matters which may endanger or interrupt customer service, loss to the organizational brand or image in the market.

10. Any other function or role requested from Corporate or Regional office from time to time.