Assistant Manager - Grievances

Job Responsibilities:

Follow up with Dr for Opinion and closure of approved cases by mail to complainant.

Preparation of special grievance Reports

Policy Related Complaints (Proposal rejection, refund, transfer of policy etc)

Follow up of all Policy related complaints including Special grievances with other departments/BO/ZO. Mail response to the customer directly from CRM

IRDAI Complaints (Complaints received from IGMS portal)

Review of complaints & filling of all the fields in CRM. The complaint is then taken up with Doctor for medical Opinion . After completion of medical Opinion , resolution remarks are updated in CRM for Rejection and Query cases. For medically approved cases, the ticket is moved to ROD Creation for further processing. After follow up with billing & FA team resolution remarks are updated in CRM .

Policy related and general complaints are followed up with other departments/BO/ZO and resolution remarks are updated in CRM after which System triggers auto resolution to customer email ID in SRMS.

Registered complaints received by insurer (SRMS complaints)

Registering the complaint received at Insurers end in CRM by filling in all the fields . The complaint is then assigned to the Doctor for medical Opinion . After completion of medical Opinion in CRM , resolution remarks are updated in CRM for Rejection and Query cases. System then triggers auto resolution to customer email ID in SRMS. For medically approved cases, the ticket is moved to ROD Creation for further processing. After follow up with billing & FA team , resolution remarks are updated in CRM . System then triggers auto resolution to customer email ID in SRMS.

Policy related and general complaints are followed up with other departments/BO/ZO and resolution remarks are updated in CRM after which System triggers auto resolution to customer email ID in SRMS.

Report preparation

GRP, PRAGATI , DSR murthy sir report, Fortnight report and Form NL 45

Maintaning Department Attendance

PG&NCH Complaints.

Review of complaints & filling of all the fields in CRM and Assisgning to doctor for medical Opinion . After medical Opinion completed, for query and rejected cases resolution remarks are updated in PG/NCH.

For medically approved cases, the ticket is moved to ROD Creation for further processing. After follow up with billing & FA team resolution remarks are updated in PG/NCH Portal.

For policy, related and general complaints follow up with other departments/BO/ZO and resolution remarks are updated in PG/NCH portal.

For PG complaints, resolutions are sent to customer through mail additionally and mail copy is also attached in PG portal.

ROD Creation (IRDAI, PG & NCH)

ROD creation is done for IRDAI, PG & NCH complaints which are medically approved and moved for further processing.

ROD & Co-Ordination

ROD Creation for medically approved cases, Co-ordination with doctors and non-medical team.

Billing

Verifying the bills

Understanding the customer grievance

Calculating Non-medical items

Tallying the claimed amount

Verifying the overall payable amount

Verifying policy sublimit ./co-pay if any.

Financial Approval

Cross Verifying amount entered by billing team

reverify the Non-medical items as per policy condition

To verify the accumulated bonus

understanding the customer grievance

arriving admissible amount after deducting copay /sublimit

Verifying the policy period and status of the policy status while processing the claim.

Checker & Makers

Uploading the Opinion in galaxy

Ensuring the fields in CRM are completely filled

closing the FA approved tickets and sending resolution to insured

following up with concern department for the tickets kept under internal department pending

alerting concern ticket owner to resolve higher ageing claims to close

Data extraction/ preparation for multiple reports .

coordination with Doctors , ZGO claims team for follow ups and early resolution.