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Digit Insurance
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Health Claims - Process & Quality Improvement

Health Claims - Process & Quality Improvement

Digit Insurance

0 years

0 Lacs

bengaluru karnataka india

Posted:1 day ago| Platform:

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Skills Required

compliance lean sigma processing audit training management efficiency dmaic mapping analysis fmea design automation support digitization risk documentation audits collaboration service metrics leadership certifications healthcare engineering certification data excel power communication regulations

Work Mode

On-site

Job Type

Full Time

Job Description

Job Title: Quality and Process Manager – Health Claims OperationsLocation: BangaloreDepartment: Health Claims OperationsReports To: Head of Health ClaimsEmployment Type: Full-Time

Job Summary

We are seeking a highly analytical and process-driven Quality and Process Manager to lead quality assurance and process improvement initiatives within our Health Claims Operations team. This role is critical in ensuring claims are processed accurately, efficiently, and in compliance with regulatory standards, while driving continuous improvement across workflows and systems using Lean Six Sigma methodologies.Key ResponsibilitiesQuality Assurance

Develop and implement quality control frameworks for health claims processing.
Monitor and audit claims to ensure accuracy, compliance, and timeliness.
Identify root causes of errors and lead corrective action plans.
Collaborate with training teams to address knowledge gaps and improve performance.

Process Management

Apply Lean Six Sigma principles to identify and eliminate waste, reduce variation, and improve process efficiency.
Lead DMAIC (Define, Measure, Analyse, Improve, Control) projects to optimize claims workflows.
Conduct Value Stream Mapping and Failure Mode and Effects Analysis (FMEA) to assess process risks and opportunities.
Design and implement standardized operating procedures (SOPs) aligned with Six Sigma best practices.
Coordinate with IT and automation teams to enhance system capabilities and support process digitization.

Compliance & Risk

Ensure adherence to regulatory requirements (IRDAI, HIPAA, etc.).
Maintain documentation for audits and regulatory inspections.
Monitor risk indicators and escalate potential issues proactively.

Stakeholder Collaboration

Work closely with claims processors, medical review teams, and customer service.
Liaise with external partners such as TPAs, hospitals.
Present performance metrics and improvement plans to senior leadership.

Key Performance Indicators (KPIs)

Claims accuracy rate
Turnaround time (TAT) improvement
Reduction in rework and escalations
Compliance audit scores
Process improvement ROI
Number and impact of Lean Six Sigma projects completed

Qualifications & Skills

Education & Certifications

Bachelor’s degree in healthcare administration, Business, Engineering, or related field
Lean Six Sigma Green Belt certification required; Black Belt preferred
Additional certifications in quality management (e.g., ISO, TQM) are a plus

Skills

Strong knowledge of health claims lifecycle and adjudication processes
Proficiency in Lean Six Sigma tools: SIPOC, Fishbone Diagram, Control Charts, Pareto Analysis, etc.
Advanced data analysis skills using Excel, Power BI, or statistical software
Experience leading cross-functional process improvement projects
Excellent communication, leadership, and stakeholder management skills

Preferred

Experience with digital claims platforms and automation tools
Familiarity with Indian health insurance regulations and global best practices
Ability to thrive in a fast-paced, high-volume environment

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Digit Insurance

Insurance

Bengaluru Karnataka

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Health Claims - Process & Quality Improvement