Assistant Manager Mass Health Claims

4 - 6 years

5 - 9 Lacs

ahmedabad

Posted:1 day ago| Platform: Naukri logo

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Skills Required

relationship management fraud control claims tpa external audit process improvement mis analytics monitoring system implementation

Work Mode

Work from Office

Job Type

Full Time

Job Description


  1. High Value Claims Management - Cashless claims

    1. Setting up guidelines for processing health cashless claims

    2. Seek expert opinion on rejection/repudiation of HV claims.

    3. Active coordination with ILM for closure of investigations within TAT





  1. Medical Guidelines Cashless Claims Management

    1. Set up medical claim processing criteria.

    2. Set guidelines for in-house claims review.

    3. Execute process improvement feedback.

    4. Active participation in Internal & External audit of the department





  1. Monitoring overall hospital service utilization.

    1. Work on data analytics fraud framework.

    2. Stringent monitoring & executing control measures of service over utilization by providers.

    3. Identify patterns and set triggers for suspicious claims.

    4. Coordinate with MIS/Analytics for various reports.

    5. Work with Analytics team to set up HAT fraud control measures.





  1. Relationship management

    1. Collaboration with internal processing teams - medical and technical, ILM and providers, aligning thought process for uniformity in decisions.

    2. Engagement with HAT Project team for effective core system implementation

    3. Liaison with TPA team for periodic audits and trainings for the TPA on identified gaps.

    4. Ensure strict adherence to the agreed SLAs of dependent teams



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Bajaj General Insurance Ltd

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