Dr Bhavani

CLAIMS MANAGEMENT:

Medical management of Reimbursement, Cashless, Hospital cash claims, Personal Accident and Critical Illness claims

Supervise end to end claims processing, timelines & compliance with policy terms and conditions.

|Ensure claims adjudication is consistent with policy terms & regulatory standards.

Implement a quality control system, lowering claim processing errors by 25%

Analyze claims data to identify trends, patterns of fraud prevention and policy design

Promptly addressing customer complaints & grievances through proper service delivery, review and effective grievance mechanism

Monitor performance metrics (TAT's, Settlement Ratios ) and drive continuous improvement initiatives

Optimize cost control without compromising customer satisfaction and regulatory compliance

TEAM LEADERSHIP:|

Conduct periodic performance evaluation and identify upskilling needs

Conduct strategic workforce planning, training programs and development needs

Foster a culture of performance innovation and accountability across the claims team

COMPLIANCE |& QUALITY CONTROL:

Ensure end to end compliance with IRDAI and other regulatory authorities.

Lead external and internal audits, execute corrective measures and suggestions.

|Stay abreast of relevant health regulations,insurance laws,company policies to ensure all claim processing activities adhere to legal and ethical standards.

PROCESS IMPROVEMENT:

Identify bottlenecks and recommend process or system changes to optimize operations

Collaborate with IT and product team to oversee automation or digital transformation and system upgrades in the claims workflow

STAKEHOLDER ENGAGEMENT:

Collaborate with cross-functional leadership teams (Underwriting, Customer Service, Legal, IT) for seamless operations

Act as the principal liaison with TPA's, Hospital networks and other strategic partners

REPORTING & DOCUMENTATION:

Maintain accurate documentation and records for claim audits and MIS requirements

Present management reports,risk assessments and improvement proposals to the execute leadership

Periodic filling of data to IIB, GIC and IRDAI