Health Claims Professional
2 days ago
Job Title: Quality and Process Manager Health Claims Operations
Location: Bangalore
Department: Health Claims Operations
Reports To: Head of Health Claims
Employment 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 Responsibilities
Quality 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 & SkillsEducation & Certifications
- Bachelors 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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