Head – Reimbursement claims

Job Description:

Primary Role Description: The individual will head reimbursement claims process (Claim reporting to final decision). He / She will play a key leadership role in driving Reimbursement claim strategy, managing the claims team, collaborating with other departments to ensure the organizational goals on finances, customers, processes and people are met.

Key Roles & Responsibilities:

1. Leadership and Management:

• Lead and manage the health claims team of 135 people to ensure optimal performance and efficiency in the claims adjudication process.
• Set objectives, provide training, and coach the team to meet departmental goals and KPIs.
• Foster a collaborative environment between the claims department and other internal departments, such as underwriting, customer service, and sales.
• Ensure that the team remains compliant with internal policies, industry standards, and government regulations

2. Claims Process Management:

• Supervise and streamline the end-to-end health reimbursement claims process, ensuring claims are processed in a timely, efficient, and accurate manner.
• Implement and refine processes for claim adjudication, coding, and payment, ensuring compliance with healthcare standards (e.g., ICD codes, CPT codes).
• Oversee claim validations, review of medical documentation, and interaction with healthcare providers to resolve discrepancies
• Manage re-represented claims through Litigation processes
• Interact with key opinion makers in the industry for second opinion or to define and/or improve approaches and processes
• Develop and improve SOPs for key reimbursement processes
• Regular review of key KPIs and publication of report to key stakeholders
• Manage, review and govern all TPAs associated with the company for claims processes of group policies.

3. Strategic Planning and Analysis:

• Help with and Implement strategies as decided by the management for improving claim accuracy, reducing claim processing times, and enhancing customer satisfaction.
• Analyze claims data and trends to identify opportunities for improvement, fraud prevention, and cost management.
• Prepare regular reports for senior management, outlining key performance metrics, trends, and operational challenges.

4. Compliance and Regulatory Oversight:

• Ensure the health claims process adheres healthcare regulations and ensure the operations and approaches of the department are compliant with necessary regulations
• Stay informed of changes in healthcare legislation, policies, and industry trends that could impact claims management and adjust processes accordingly.
• Conduct periodic audits and internal reviews to identify areas of non-compliance and implement corrective actions.

5. Customer Experience and Satisfaction:

• Monitor customer feedback and claims-related inquiries to ensure the highest levels of customer satisfaction.
• Resolve escalated claim disputes and complex cases, working closely with both internal and external stakeholders.
• Develop and implement improvements to the claims communication process to enhance transparency and ease for policyholders.

6. Risk and Fraud Management:

• Identify and manage potential risks associated with health claims, including fraud, abuse, and over-utilization.
• Implement fraud detection tools and collaborate with the fraud prevention team to address suspicious activities.

7. Collaboration with External Partners:

• Work closely with external providers, network managers, and third-party vendors to ensure proper claims handling.
• Maintain relationships with healthcare providers, TPAs and billing organizations, and medical practitioners to ensure accurate claim submission and processing.

Key Requirements:

Education & Certificates: Preferably MBBS 

Experience & Skills: Minimum of 10-12 years of claims management with at least 3-4 years in management of cashless/reimbursement process in a leadership role (Chief manager/AVP)