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Aditya Birla Capital Limited
Aditya Birla Capital Limited (“ABCL”) is a listed systemically important non-deposit taking Non-Banking Financial Company (NBFC) and the holding company of the financial services businesses. ABCL and its subsidiaries/JVs provides a comprehensive suite of financial solutions across Loans, Investments, Insurance, and Payments to serve the diverse needs of customers across their lifecycles. Powered by over 63,750 employees, the businesses of ABCL have a nationwide reach with over 1,712 branches and more than 200,000 agents/channel partners along with several bank partners.
Nationwide Branches
1,712
No. of Employees
63,750+
Agents/Channel Partners
2,00,000+
Aggregate Assets
INR 5.50 Lakh Cr
Active Customer Base
39 Million
Consolidated Lending Book
INR 1.78 Lakh CrCorporate Governance Policies
- Policy for appointment of Statutory Auditors
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- Fair Practices Code
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Job Description
Team Member - Case Management
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Job Description
PFB JD for Case Management TM (team member)
Job Position: AM / DM / Manager
Location: Thane Mumbai
Department: Ops Claims
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Job Summary:
We are seeking detail-oriented individuals to join in our highly dynamic and fast growing case management team in claims operations.
It involves the timely coordination of quality healthcare services to address a client’s specific needs in a cost-effective manner to promote optimal outcomes for customers.
This role focuses on reviewing, analysing the claims, identifying and resolving the abuse, inflation in claims, adherence to policy terms.
The ideal candidate will ensure compliance with policies, prevent financial losses, and uphold the integrity of the claims process while collaborating with internal teams and external healthcare providers with customer centric approach.
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Key Responsibilities:
1. Claim Review:
- Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.
- Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts, standard treatment guidelines and protocols
2. Cost Management, Utilization Review:
- Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes
Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.
- Conduct audits of high-risk claims and hospital billing practices.
3. Communication and Collaboration for Resolution
- Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.
- Identify non-compliance and get corrective action on identified non-compliant via direct communication for quick resolution.
- Real time coordination with hospitals to clarify discrepancies and ensure adherence to approved treatment protocols for facilitating best customer experience during their claim.
4. Documentation, data analysis & Reporting
- Maintain records of case progress, Identify trends
- Prepare and maintain reports on findings, recommendations for process improvements.
5. Patients advocacy, continuous Learning and quality improvement:
- Educate internal and external stake holders on ethical practices and billing abuse, policy / contract terms
- Stay updated on healthcare regulations, coding standards (ICD, CPT), and emerging fraud tactics.
Education:
Bachelor’s degree in Medicine (MBBS/BAMS/BHMS), MBA in Healthcare Management, or related field.
Experience:
Minimum 2-3 yrs. experience preferably in Hospitals TPA department, Health Insurance, Claim processing, Claim investigation,
Knowledge Requirement:
- Familiarity with cashless claim processes, TPAs, and insurer-provider contracts.
- Understanding of health insurance policy terms, Clinical protocols, medical coding (ICD-10, CPT), IRDAI guidelines
Skills:
- Strong clinical knowledge and analytical and problem-solving abilities.
- Excellent communication for negotiations and stakeholder collaboration.
- Proficiency and knowledge of MS Excel, PowerPoint and/or analytics tools
- Knowledge of health insurance terms and IRDA guideline
- Customer first approach and detail oriented
Key Competencies:
- High ethical standards and attention to detail.
- Ability to manage multiple cases in a fast-paced environment.
- Critical thinking to assess complex claims and billing patterns.
-Quick learner and Process oriented.
Work Environment
Work from Office, 5 working days in a week
1 - 4 years
02 degree
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