01Key Responsibilities
Map end-to-end claims process: intimation adjudication approval payment.
Define workload balancing logic and queue management rules for claims teams.
Design data and process interfaces with TPAs (EDI/API structures).
Define claim status taxonomy, turnaround times, and escalation hierarchies.
Support configuration of fraud triggers and quality checks.
Ensure regulatory compliance for cashless and reimbursement claim processing.
Skills & Experience:
4-5 years in health claims operations (retail/group), with process re-engineering experience.
Experience working with TPAs and API data exchanges in India.
Familiar with claims systems (e.g., MediAssist, Raksha, Core IT platforms).
Strong analytical and problem-solving skills for system testing and exception handling.
Proven ability to translate business process logic into system requirements.
Skilled in as-is and to-be mapping, gap analysis, and workflow design.
Experience working with IT development and QA teams on core insurance systems.
Deep understanding of IRDAI regulations, esp. regarding claims management and customer grievance reporting.
Excellent documentation, analytical, and stakeholder management skills. .
