2 Claims Resolutions Jobs

Role & responsibilities A) Claims 1. ZOCAs shall be the main link between Zonal team and the HO Claims and will coordinate in such a way that the Claims resolutions are made quicker and creates customer satisfaction. 2. Track claims from intimation to payments of money in the claimants accounts. Attend to the full lifecycle of the claim. 3. Any bottlenecks in upload of claims, either from office, customers portal, agents Portal, agents Virtual Office , Star Health App or physical hand over of documents to Office, to be reported & addressed. 4. Handle any bottlenecks in payment like non-availability of NEFT / Payee / Nominee details 5. ZOCA shall be responsible for speedy & accurate delivery of claims to the Customers of the Zone. However, the position will not have any claims settlement authority, unless specifically given. 6. Shall be responsible for the quality & efficiency of uploading / ROD/ Billing at Zonal levels. 7. Shall attend to the complaints from agents and other marketing personnel, check the status of the claims, inform them about it, coordinate with Corporate team on any delayed claims, follow up coordinator/ query requirements etc . For this they shall use the Escalation matrix already laid down. 8. For issues in cashless claims they shall be in touch with Claims processing Drs 9. Work as an Early Warning system to avoid any bottlenecks that may be getting developed at local levels. This could be spread of local contagious infections like Dengue, resignation of critical personnel, hospitals over charging claimants etc. 10. Inform to Corporate Claims, areas which may bring in high claims ratios like identified Agents / SMs/ Branch Offices to take preventive measures 11. Coordination with Zonal Grievance coordinators for speedy resolution of grievances related to claims. 12. Checking and confirming that various SMS / E mails from Claims dept are reaching the target customers by looking at random samples. 13. Shall check the efficacy of IT systems and if any deficiencies are noted at ground levels, suggestions may be provided to HO Claims. 14. They shall popularize the usage of Star Health App among customers and VO / Atom app among Agents and SMs 15. Ensure that the reimbursement claims of OPD & Preventive Health Care ( PHC) & Pre approval Tests are settled at Zonal Office quickly and efficiently Fraud Mitigation 1. ZOCAs to keep a watch out for any fraudulent activities going in any Hospitals, groups of agents, SMs which could lead to Fraudulent claims 2. Keep an alert on High ICR Branches for any tendencies on fraud within employees. 3. Provide necessary support to FVR/ Vigilance officer / Fraud investigator B) Hospital related (to work in coordination With Regional HRM Head & HRMs) 1. Issues faced by Hospitals in connecting to the Cash less team, getting pre Auth & auth and also uploading of bills in SPP or Vitreya portals. 2. Shall also coordinate with Zonal HRM team to ensure that the Zone has very effective and large Network of hospital 3. Take up with Hospitals to reply to the letters written by CHAIR / Triage seeking explanations. Coordinate with HRMs to arrange VCs with the Hospital as required by CHAIR VC team 4. Arrange TPA desk training frequently and submit reports to HO. 5. Coordinating with Hospitals to get the correct identity of Director of medical services, treating Drs etc for corporate claims to negotiate with the Hospital 6. Coordinating with HRMs / Hospital for PCC operations 7. Please bring to the attention of Claims team if any Hospital continuously bad mouths us. 8. Bring to the attention of EPPM/ Claims if it is known that our network Hospitals charges us more than other health insurers. C) Administration 1. Overseeing the functions & performance of the Claims team reporting to you. The expected roles of Zonal Claims Coordinators 2. Zonal Claims Head shall oversee, guide, train and develop the functions of Zonal Claims coordinators. 3. Discipline to be maintained in the Claims team. This including the attendance, approved leaves, WFH to be clearly approved etc. 4. Check on actual tours, geo tagging facilities extended etc. 5. Organize reviews of High ICR branches with the help of Commands. 6. Shall ensure that the claims team has adequate resources at all times. ZOCA also shall follow up with Training Academy and Zonal trainers to provide continuous training to the claims team. 7. Arranging/ coordinating delivery of training to agents / marketing team on new developments on claims side, in coordination with Zonal Trainers. 8. To submit biweekly reports to Corporate Office on all activities in the specified formats. 9. To keep Corporate Claims informed about any matters which may endanger services to customers, aggravation of losses or negative image in the market. 10. Any other function or role requested from Corporate Office from time to time. D) Reporting ZOCAs will report to Regional / Zonal Head (depending on the office in which he / she reports) who will be L1 and Command Head will be L2.

Role & responsibilities A) Claims 1. ZOCAs shall be the main link between Zonal team and the HO Claims and will coordinate in such a way that the Claims resolutions are made quicker and creates customer satisfaction. 2. Track claims from intimation to payments of money in the claimants accounts. Attend to the full lifecycle of the claim. 3. Any bottlenecks in upload of claims, either from office, customers portal, agents Portal, agents Virtual Office , Star Health App or physical hand over of documents to Office, to be reported & addressed. 4. Handle any bottlenecks in payment like non-availability of NEFT / Payee / Nominee details 5. ZOCA shall be responsible for speedy & accurate delivery of claims to the Customers of the Zone. However, the position will not have any claims settlement authority, unless specifically given. 6. Shall be responsible for the quality & efficiency of uploading / ROD/ Billing at Zonal levels. 7. Shall attend to the complaints from agents and other marketing personnel, check the status of the claims, inform them about it, coordinate with Corporate team on any delayed claims, follow up coordinator/ query requirements etc . For this they shall use the Escalation matrix already laid down. 8. For issues in cashless claims they shall be in touch with Claims processing Drs 9. Work as an Early Warning system to avoid any bottlenecks that may be getting developed at local levels. This could be spread of local contagious infections like Dengue, resignation of critical personnel, hospitals over charging claimants etc. 10. Inform to Corporate Claims, areas which may bring in high claims ratios like identified Agents / SMs/ Branch Offices to take preventive measures 11. Coordination with Zonal Grievance coordinators for speedy resolution of grievances related to claims. 12. Checking and confirming that various SMS / E mails from Claims dept are reaching the target customers by looking at random samples. 13. Shall check the efficacy of IT systems and if any deficiencies are noted at ground levels, suggestions may be provided to HO Claims. 14. They shall popularize the usage of Star Health App among customers and VO / Atom app among Agents and SMs 15. Ensure that the reimbursement claims of OPD & Preventive Health Care ( PHC) & Pre approval Tests are settled at Zonal Office quickly and efficiently Fraud Mitigation 1. ZOCAs to keep a watch out for any fraudulent activities going in any Hospitals, groups of agents, SMs which could lead to Fraudulent claims 2. Keep an alert on High ICR Branches for any tendencies on fraud within employees. 3. Provide necessary support to FVR/ Vigilance officer / Fraud investigator B) Hospital related (to work in coordination With Regional HRM Head & HRMs) 1. Issues faced by Hospitals in connecting to the Cash less team, getting pre Auth & auth and also uploading of bills in SPP or Vitreya portals. 2. Shall also coordinate with Zonal HRM team to ensure that the Zone has very effective and large Network of hospital 3. Take up with Hospitals to reply to the letters written by CHAIR / Triage seeking explanations. Coordinate with HRMs to arrange VCs with the Hospital as required by CHAIR VC team 4. Arrange TPA desk training frequently and submit reports to HO. 5. Coordinating with Hospitals to get the correct identity of Director of medical services, treating Drs etc for corporate claims to negotiate with the Hospital 6. Coordinating with HRMs / Hospital for PCC operations 7. Please bring to the attention of Claims team if any Hospital continuously bad mouths us. 8. Bring to the attention of EPPM/ Claims if it is known that our network Hospitals charges us more than other health insurers. C) Administration 1. Overseeing the functions & performance of the Claims team reporting to you. The expected roles of Zonal Claims Coordinators 2. Zonal Claims Head shall oversee, guide, train and develop the functions of Zonal Claims coordinators. 3. Discipline to be maintained in the Claims team. This including the attendance, approved leaves, WFH to be clearly approved etc. 4. Check on actual tours, geo tagging facilities extended etc. 5. Organize reviews of High ICR branches with the help of Commands. 6. Shall ensure that the claims team has adequate resources at all times. ZOCA also shall follow up with Training Academy and Zonal trainers to provide continuous training to the claims team. 7. Arranging/ coordinating delivery of training to agents / marketing team on new developments on claims side, in coordination with Zonal Trainers. 8. To submit biweekly reports to Corporate Office on all activities in the specified formats. 9. To keep Corporate Claims informed about any matters which may endanger services to customers, aggravation of losses or negative image in the market. 10. Any other function or role requested from Corporate Office from time to time. D) Reporting ZOCAs will report to Regional / Zonal Head (depending on the office in which he / she reports) who will be L1 and Command Head will be L2.