Assistant Vice President- Claims-Operations

JOB DESCRIPTION

PURPOSE OF ROLE

Providing operational leadership to the Central Operations function ensuring quality, productivity, utilization of

manpower and adherence to SLA.

Designation AVP- Central Operations

Function Central Operations - Supervisor

Location Bangalore

Educational Qualification MBA / Any IT Professional / BAMS / BHMS / MBBS

Industry Type TPA / Insurance / Healthcare

Roles and Responsibilities

Claims Processing Metrics

• Claims Settlement Cycle Time: Average days from claim receipt to

payment, targeting quick resolution to enhance member satisfaction

• Claims Denial Rate: Percentage of claims rejected, indicating

adjudication accuracy and policy compliance.

• Claims Processed Per Employee: Volume handled per staff member,

measuring operational productivity.

Financial and Efficiency Metrics

• Medical Loss Ratio (MLR): Portion of premiums spent on claims,

ensuring balanced financial health.

• Cost per Claim: Total expenses per processed claim, optimizing

resource use.

• Operational Efficiency Rate: Ratio of value-added work to total

efforts, aiming for 85-90%

• Profit & Loss (P&L) responsibilities and ensure adherence to the

Annual Operating Plan (AOP) for Operations (both hubs and central

operations). Role will now include overseeing staffing requirements for

all hubs and central teams, further strengthening operational

effectiveness across the function.

Service and Compliance Metrics

• First Contact Resolution Rate: Percentage of issues resolved on initial

interaction for members or providers.

• Prior Authorization Response Time: Average minutes to respond to

pre-approval requests.

• SLA Compliance Rate: Adherence to service level agreements on

turnaround and accuracy.

• Implementation of claims operations strategy. Ensure people and

claims related processes are managed efficiently.

• Oversee distribution of claims work to the teams. Ensure

maintenance of quality and productivity standards at a high level.

• Improve process efficiency through business process re-engineering/

automation in order to process more claims with optimal resources.

• Monitor all the outstanding claims. Ensure outstanding claims do not

exceed 30 days.

Relevant Experience Strong experience in Central Operations / Branch Operations / Claims

processing in a TPA / Insurance

Total Experience 8-12 years with an insurance / hospital management experience

• Ability to advise and guide with appropriate Operational / finance /

medical knowledge to the team.

• Ability to handle team

Technical Competencies

Analytical Ability

• Operational Excellence
• Problem Solving & Decision Making

Behavioral competencies

Collaboration

• Communication
• People Management
• Stakeholder Management

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