PHI - Assistant Manager- Claims Management

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed. Prudential (UK) in partnership with HCL group plans to set-up a standalone Indian health insurance company to address the growing healthcare needs of the Indian consumer. This joint venture will combine Prudential's global expertise in insurance and financial services with HCL Group’s experience in technology and healthcare solutions. Prudential, with its longstanding presence in India, already operates two leading businesses in life insurance and asset management with the ICICI Group. Prudential was also the proud sponsor of the 1983 Cricket World Cup, India’s first World Cup Victory! Prudential Health India is a Zero to One team undertaking a no-legacy, greenfield health insurance deployment in India, building journeys that truly empathize with the customer and offer a differentiated experience. To partner with us in this mission, we are looking for a talented Assistant Manager – Claims Management to join our Experience team in Mumbai. Assistant Manager – TPA Claims Management As an Assistant Manager Claims, your typical week might include the following: Guiding TPA processing team by providing medical opinion for Health Insurance Claims Ensure claims of valid settlements are made according to the company practice and procedures. Processing and approving medical claims pertaining to Indemnity, Benefit for both Group and Retail, with sharp FWA and Loss minimization approaches. Thorough on the compliance and regulatory requirements and implementation in the claims process. Case management of potential cases to Network team, maintaining data of referred/saving achieved/impact against cashless outgo. Automation and rule driven decision making with timely update of benefit in TAT / TMS / Transaction Create and reviewing claim simplification guidelines to Improve TAT, Minimize transaction. Medical decisioning and guidance to the team Audit of TPA processed claims and also Inhouse processed claims. Regulatory compliances – Claim processing guideline as per compliance and timely implementation of any New Circular. Train TPA teams – Timely Training of TPA for new benefit, process change, Understanding and claim Philosophy as per PHI standard. Benefit claims – Well versed with processing of Benefit claims, Creating SOP, Pay-out framework to Nominee/Legal heir. Collaborate with FWA Manager to provide inputs from agencies for efficient Fraud restriction and necessary checks and balances in system. Re-UW opinion for non-disclosure cases – Training to Team for indicated cases for Re-UW referral, tracking and corrective action basis UW decision. Extend support to the sales/distribution – Separate prioritization que for green channel, Specific Agent, Broker. Set up and create robust governance to manage TPA process with great efficiency. Proficient with medical terms & systems (including ICD/CPT/PCS codes). You could be the right candidate if you… Are a doctor by training (/BAMS/BHMS/BDS) Have 03-05 years’ experience of health Insurance claim processing management with at least 1-2 years’ experience as team leader managing and holding responsibility daily claim flow. Understands the TPA ecosystem and has experience of managing TPA model (Preferred) Have startup experience or setting up a team from scratch (Preferred but not mandatory) Should be a decisive & creative individual. Should be able to make quick decisions and have good judgment and analytical skills Have an excellent verbal and written communication skills and strong negotiation skills. Always