GM/AVP - Quality Management and L&D

Job Description:

Primary Role Description: - Responsible for leading claims-focused training, learning & development, and quality management across Financial and Medical claims operations. The role ensures high-quality, compliant, and efficient claims processing through robust training frameworks, continuous learning initiatives, and quality assurance programs.

Key Roles & Responsibilities:

• Design and deliver structured training programs for Financial and Medical claims processing teams.
• Develop claims curricula, SOPs, job aids, and refresher modules aligned with regulatory and company standards.
• Creation, periodic review and update of claims quality management plan
• Sample based review of medical and financial adjudication to identify errors and plan mitigation
• To ensure existence of a no critical error and minimal non-critical error process.
• Coordinate with internal audit team to plan and execute periodic claims audit
• Run clinical governance across all functions housing clinical experts.
• Implement and manage claims quality assurance frameworks, audits, and root cause analysis.
• Monitor claims accuracy, compliance, turnaround times, and customer impact metrics.
• Partner with Operations, Medical, Finance, Compliance, and Technology teams to address quality gaps and process improvements.
• Drive continuous learning initiatives, certifications, and upskilling for claims professionals.
• Track training effectiveness and quality outcomes using KPIs, dashboards, and reporting.

Key Requirements:

• Prefer MBBS Graduate/Postgraduate in Healthcare, Insurance, Finance, or related field
• 8–12 years of experience in Health Insurance Claims, with exposure to Training and Quality functions

• Strong understanding of Health Insurance claims—Financial and Medical

• Expertise in Claims Quality Management and Audit Processes
• Learning & Development / Training Design experience
• Knowledge of regulatory and compliance standards
• Analytical, stakeholder management, and communication skills