PHI - 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 Manager – Claims Management to join our Experience team in Mumbai. Manager - Claims Management As a Manager Claims, your typical week might include the following: Guiding 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. Creating detailed standard operating process for seamless functioning of claims adjudication 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. Manage floor – people and SLA (TAT) – create roster, manage adequate manpower on daily basis, especially on weekends and public holidays. Audit of TPA processed claims and also Inhouse processed claims. Medical decisioning and guidance to the team Analytics and Dashboard – Dashboard preparation to Manage TAT, Cost vector (ACS, Pay-out ratio), Loss ratio, CS:RI ratio and regional distribution. Support to Group UW team for providing claims analytic input like Specific trend related to FWA, Frequency, Loss ratio, utilization of particular benefit. Regulatory compliances – Claim processing guideline as per compliance and timely implementation of any New Circular. Litigation cases – Claim related to Input and evidence in SCN (Self-containment note) to make our stand stronger in Ombudsman/any other legal forum. 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). Collaborate with