Prudent Insurance Brokers
1 week ago
Job Title: Senior Manager - Claims (Employee Benefits)Department: Claims & OperationsReports to: Head - Claims/OperationsJob Summary:The Senior Manager - Claims will be responsible for leading and overseeing the Employee Benefits (EB) claims team, ensuring smooth and efficient claims processing across cashless and reimbursement cases. The role requires strong stakeholder management with TPAs, insurers, and client HR teams, along with expertise in health insurance processes and regulatory frameworks. This position involves both strategic leadership and hands-on operational management to ensure SLA adherence, client satisfaction, and accurate claims resolution.Key Responsibilities:Team Leadership & Operations:- Lead, mentor, and manage the EB claims team to achieve performance benchmarks and minimize escalations.- Allocate workload effectively, monitor productivity, and ensure adherence to quality standards.- Conduct regular training sessions to enhance team knowledge on policy terms, insurance guidelines, and process updates.- Drive process improvements and automation initiatives to enhance efficiency.Claims Management:- Oversee end-to-end processing of EB claims (cashless & reimbursement) while ensuring compliance with policy terms and regulatory guidelines.- Review denial claims shared by TPAs and validate them against policy conditions.- Represent client claims to insurers/TPAs in case of settlement or denial ambiguities.- Provide subject matter expertise on medical practices and insurance policies during claim reviews.Stakeholder Management:- Build and maintain strong relationships with TPAs and insurers to ensure SLA adherence and timely claims settlement.- Collaborate with client HR teams to resolve claims-related escalations and queries.- Communicate policy terms, claims procedures, and resolutions effectively to clients via calls, emails, or meetings.- Visit insurer offices when required to expedite approvals and resolve complex claims.Compliance & Reporting:- Ensure compliance with IRDAI health insurance regulations and company policies.- Monitor and track payment cycles, denial trends, and settlement turnaround times.- Support the Analytics team with data insights and claims trend analysis.- Prepare periodic MIS/reports for management on claims performance, outstanding amounts, and process efficiency.Desired Profile / Candidate Graduate in any specialization (mandatory).- Postgraduate degree or certifications in Insurance, Risk Management, or Healthcare Administration 10-15 years of experience in Employee Benefits (EB) claims management.- Strong expertise in handling EB claims processes (cashless & reimbursement).- Proven experience in managing teams and stakeholder relationships in the TPA/insurance domain.Skills & Competencies:- In-depth knowledge of health insurance policies, terms, and exclusions.- Familiarity with current medical practices and advancements.- Strong understanding of IRDAI health regulations and compliance requirements.- Excellent communication and presentation skills (verbal and written).- Problem-solving and decision-making capabilities with a customer-first mindset.- Strong leadership, mentoring, and people management skills.- Ability to work under pressure and manage escalations effectively. (ref:iimjobs.com)
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