TataAIG - Manager - Health Claims
2 weeks ago
As Manager - Health Claims, you will play a critical role in adjudicating and managing health insurance claims by integrating clinical knowledge with data-driven decision-making. You will ensure claims are processed accurately, within regulatory and company guidelines, while maintaining operational excellence and customer trust.This position involves a blend of medical expertise, analytical judgment, and process governance, supported by Tata AIGs advanced claims management systems.Key Responsibilities1. Claims Assessment & Review and evaluate health insurance claims using your medical knowledge to determine clinical admissibility.- Analyze medical documents, discharge summaries, diagnostic reports, and treatment details to ensure alignment with policy terms and conditions.- Apply evidence-based medical judgment to support approval or rejection decisions.- Identify inconsistencies or anomalies in claims and escalate for further medical or fraud review.2. Policy & Regulatory Compliance- Interpret and apply policy wordings, inclusions/exclusions, and regulatory guidelines during claims processing.- Ensure all adjudications comply with IRDAI standards, internal audit norms, and Tata AIGs governance policies.- Maintain up-to-date understanding of healthcare regulations, clinical protocols, and insurance compliance frameworks.3. Process Excellence & Automation- Leverage Tata AIGs claims management system (CMS) and digital tools for efficient case tracking and workflow automation.- Support the integration of AI/ML-based decision engines that assist in predictive analysis and fraud detection.- Contribute to the optimization of claims turnaround times (TATs) and enhancement of processing accuracy through data-driven insights.4. Quality Review & Auditing- Conduct peer reviews and quality checks on processed claim files to ensure accuracy and adherence to medical and procedural standards.- Collaborate with internal audit and compliance teams to drive zero-defect processing.- Support internal training programs on claims quality improvement and knowledge sharing.5. Grievance & Escalation Management- Manage customer grievances related to health claims in coordination with service and legal teams.- Analyze root causes of escalations and recommend process-level improvements to minimize recurrence.- Ensure all grievance resolutions meet defined TATs and service-level benchmarks.6. Fraud Detection & Risk Mitigation- Identify patterns indicative of fraudulent or inflated claims through analytical review of cases.- Collaborate with the Special Investigation Team (SIT) to validate clinical and billing authenticity.- Contribute to building a database of suspicious claim behaviors and help strengthen preventive controls.Qualifications & BAMS or BHMS Freshers and early-career professionals are encouraged to apply.- Prior experience in clinical practice, Third-Party Administrators (TPA), or health insurance claim processing will be advantageous.Technical Competencies:- Familiarity with claims management or hospital information systems (HIS).- Basic understanding of Excel-based reporting, MIS tools, and data validation workflows.- Exposure to digital health platforms or electronic medical records (EMR) will be a plus. (ref:iimjobs.com)
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