Lead - Claims (Thane)

• Job Purpose: Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters)
  
  

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 ad-hoc 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 inter-department coordination with all stakeholders including sales, finance, internal claims and actuary teams.

• Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.
  
  

Business Workforce Number

(Max 254 Characters)

6

Unit Workforce Number

(Max 254 Characters)

Function Workforce Number

(Max 254 Characters)

Department Workforce Number

(Max 254 Characters)

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

• Regulatory Submissions: Accurate and timely submission of periodic and ad-hoc 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/ad-hoc 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, Finance, Actuary, Underwriting, FWA & Internal claims team – Cashless, Reimbursement, Grievances, Group, Customer Care Team
  
  

Metric

Units

FY18B

FY19

FY20

PBT before Holdco expenses

Rs Mn

• 1,709
• 2,021
• 1,628
• Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters)
  
  

About The Health Insurance Industry –

While the current market sees more than 15 non-life 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 start-ups 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 socio-economic 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.

About The Aditya Birla Health Insurance –

Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016.

ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6th entrant in a category with well-established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of “Health Insurance for All”, a one of a kind proposition in India at the moment. This is a philosophy that is being built through every single consumer touch point and into every single backend process of the company to ensure a customer’s experience of our proposition is continuous and seamless.

ABHI’s unique offering to market includes proposition includes -

• A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
• A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1
• ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.
• ABHICL’s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.
  
  

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.
• Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)- Maximum 10 KRAs can be updated
  
  

Key Result Areas (Max 1325 Characters)

Supporting Actions (Max 1325 Characters)

Accurate and timely submission of periodic and ad-hoc reports related to Claims to the Regulatory Authority/GI Council

• Develop, Implement shortcuts, macros, formulae on excel, using alternative tools/methods for timely submission
• Develop, train the team, delegate and review their accountability
• Do cursory/sanity checks before submission
  
  

Audits: IRDA, Internal, Stat, others

Data submission/query response/ad-hoc reports to IRDA/GI Council

Closure of audit observations

• Team training, Time management, Delegation
• Strong coordination skills with other departments, sharp and on the spot thinking, proactive approach, soft skills, excel skills, working with other tools/macros
  
  

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
• Identify Data sources and do sanity checks
• Work with various tools/develop skills for analysis
• Strong coordination skills with other departments.
• Ensure collation of inputs from various areas and present the same with analysis & findings
• In case of any trends, pattern being observed analyze, investigate and table findings with suggested action areas to the senior management
  
  

Monthly / Quarterly / Annual Data submission

Policyholder’s protection committee, Quarterly board meetings, monthly Ops Review, Weekly Claims Review

• Work closely with Finance, Actuary, Operations, Internal Claims team.
• Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)
  
  

Claims Daily Dashboard –

The purpose of this role job is to effectively manage and publish the daily/weekly/monthly dashboards related to claim intimations, TAT, NPS, Settlement Ratio, average claim size, productivity, pendency, and digital metrics.

Claims MIS Regulatory Reporting –

This role is responsible for timely and accurate submissions to the Regulatory Authority on a periodic basis, as well as ad-hoc reports, and publish reports for other quarterly submissions like Policyholder’s Protection Committee, provide inputs for the Risk Management Committee, etc.

Claims MIS Analysis

Identify trends in TAT, Frauds, Settlement of Claims, Monitoring TPA performance based on defined KPI, System Development, UAT, Portfolio Analysis, Doing Root Cause Analysis of portfolio performance and MIS/Compliance

• Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives
  
  

Relationship Type (Max 80 Characters) Frequency Nature (Max 1325 Characters)

Internal

Underwriting Dept

Group Operations

Actuarial Dept

Finance Dept

Planning Dept

Legal Dept

Compliance Dept

Claims Committee

Claims Review Committee

As and when required

As and when required

Monthly

Monthly

As and when required

As and when required

As and when required

As and when required

As and when required

To obtain UW inputs on claim

To get Group/ Member info on claim

Claims settled and outstanding MIS

Claims settled and outstanding MIS & for day-to-day claim cheques.

For headcount budgeting & approvals

To get specific legal inputs on claims

To get specific Compliance inputs on claims and for taking action against the field force, if any, in repudiated cases.

To decide on complex claims, reconsideration claims and claims beyond the authority of the Claims Dept

To decide on complex claims, ex-gratia claims, reconsideration claims and claims beyond the authority of the Claims Committee

For business forecast, MIS, query resolutions etc.

For Claims status, query resolutions, MIS

For System issues, queries, testing and system developments/ enhancements.

External

Select Advisors/Brokers/Key relationships / Affinity partners

As and when required

To publish claims MIS (claims paid, outstanding, reason for outstanding, repudiated) with aging of outstanding claims.

• Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.
  
  

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)