Assistant Manager- Claims Management

In this role as an Assistant Manager Claims Management with the Prudential Health India team in Mumbai, your responsibilities will include: - Guiding the TPA processing team by providing medical opinion for Health Insurance Claims - Ensuring that claims are settled validly according to company practices and procedures - Processing and approving medical claims for both Group and Retail, focusing on sharp FWA and Loss minimization approaches - Maintaining thorough knowledge of compliance and regulatory requirements, and implementing them in the claims process - Managing potential cases by referring them to the Network team, tracking data of referrals/savings achieved/impact against cashless outgo - Implementing automation and rule-driven decision-making for timely benefit updates - Creating and reviewing claim simplification guidelines to improve TAT and minimize transactions - Providing medical decisioning and guidance to the team - Auditing TPA processed claims and in-house processed claims - Ensuring regulatory compliance in claim processing guidelines and timely implementation of any new circular - Conducting timely training of TPA teams for new benefits, process changes, and understanding claim philosophy as per PHI standard - Collaborating with the FWA Manager to provide inputs for efficient fraud restriction and checks and balances in the system - Providing re-underwriting opinion for non-disclosure cases and training the team for indicated cases - Extending support to the sales/distribution with separate prioritization queues - Setting up and creating robust governance to manage the TPA process efficiently - Demonstrating proficiency with medical terms and systems, including ICD/CPT/PCS codes Qualifications for this role: - Doctor by training (BAMS/BHMS/BDS) - 03-05 years of experience in health insurance claim processing management, with at least 1-2 years as a team leader - Understanding of the TPA ecosystem and experience in managing the TPA model (Preferred) - Startup experience or setting up a team from scratch (Preferred but not mandatory) - Decisive and creative individual with quick decision-making abilities, good judgment, and analytical skills - Excellent verbal and written communication skills, as well as strong negotiation skills - Open to embracing change and managing it effectively If you are passionate about consumer behavior and culture, enjoy understanding customer needs, like working in a collaborative culture, and are dedicated to delivering exceptional customer experiences, this role might be the right fit for you. Location: Mumbai,