Operations Manager_Health Insurance Claims

The Operations Manager – Health Insurance Claims will be responsible for overseeing and managing the end-to-end claims operations process, ensuring timely, accurate, and compliant settlement of health insurance claims. This role involves leading a team, optimizing operational efficiency, maintaining service quality, and ensuring adherence to regulatory and company policies.

Key Responsibilities

1. Operations Management

• Oversee day-to-day processing of health insurance claims (cashless & reimbursement) to ensure accuracy and timeliness.
• Monitor and manage workflows, turnaround times (TAT), and productivity levels.
• Implement process improvements to enhance operational efficiency.
• Ensure adherence to Service Level Agreements (SLAs) with insurers, TPAs, hospitals, and clients.

2. Quality & Compliance

• Ensure claims are processed in accordance with IRDAI guidelines, company policies, and internal quality standards.
• Conduct regular audits to identify errors, fraud, or gaps in documentation.
• Liaise with compliance teams to ensure risk mitigation and regulatory compliance.

3. Team Leadership

• Lead, mentor, and motivate the claims operations team to achieve performance targets.
• Allocate tasks effectively, monitor performance, and conduct periodic reviews.
• Organize training sessions to keep the team updated on insurance products, claim processes, and regulatory changes.

4. Stakeholder Management

• Maintain strong relationships with insurance companies, TPAs, hospitals, and clients.
• Resolve escalated claim disputes and complex cases.
• Provide regular operational reports and MIS to management.

5. Data & Reporting

• Analyze claim trends, turnaround times, and cost patterns to support decision-making.
• Prepare and present periodic MIS reports to senior management.
• Track and manage claim-related expenses.

Required Skills & Competencies

• Strong knowledge of health insurance claim processes (cashless & reimbursement).
• Understanding of IRDAI regulations and industry best practices.
• Excellent leadership, team management, and people skills.
• Strong analytical, problem-solving, and decision-making skills.
• Proficiency in MS Office and claims management software.
• Excellent verbal and written communication skills.

Qualifications & Experience

• Graduate in any discipline (preferably in insurance, healthcare, or business administration).
• Minimum 6–8 years of experience in health insurance claims, with at least 3 years in a managerial role.
• Experience in working with TPAs, insurers, and hospital networks preferred.

Key Performance Indicators (KPIs)

• Claims processing TAT compliance.
• Accuracy and error rate in claims.
• SLA adherence with stakeholders.
• Reduction in claim disputes and escalations.
• Employee productivity and engagement levels

Job Type: Permanent

Pay: ₹600,000.00 - ₹900,000.00 per year

Work Location: In person

Speak with the employer
+91 9288000380