Chief Medical Officer - "A&H" Claims
We at ABC Consultants are mandated to hire a Chie Medical Officer for an Insurtech startup based in Bangalore.
The firm is a rapidly growing employee healthcare benefits platform that provides flexible and customised healthcare subscriptions for SMEs, start-ups, and enterprises.
Strategic (40%):
Accident & Claims Management:
- Driving accident & health claims strategy formulation and setting up of processes for the function.
- Stays up to date on amendments and provisions in health insurance regulations & implements changes in claims processes to ensure compliance.
- Formulate & ensure near paperless claims settlement with the superior turnaround & customer experience.
- Designing, implementing & monitoring performance management parameters for TPAs & claims team.
- Training & development to medical processors. Identify critical learnings, gaps, and opportunities for individuals to develop the team.
- Build & maintain a relationship with external service partners, including but not limited to Investigators, OSP, Hospitals, etc
- Interacting, coordination & collaboration with technology teams for design & development of health claims systems that support near paperless claims management strategies.
- Work with technology & claims specialization team to automate claims processes to the possible extent.
- To provide proactive management frameworks of accident & health claims to achieve high satisfaction levels for the insured and internal stakeholders through high-quality claim management, resolution and excellent client service.
- Demonstrating thought leadership and lessons learnt from the best practices organizations as appropriate to ensure successful delivery of contracted services levels.
- Ensuring the customer is treated fairly and that the customer receives superior service within the regulatory & company guidelines.
Contributing to the growth of the business through regular interactions, support with relevant stakeholders (distribution team, intermediaries, corporates etc.)
Financial (20%):
- Close coordination with claim audit team and develop/implement health claim fraud prevention & loss mitigation framework.
- Develop, implement & manage quality assurance programmes to detect, prevent & mitigate claims leakage.
- Setting and reviewing claims budgets and managing average claims cost
- Achieve superior rate agreements with providers.
- Analyzing incurred claims ratio, review of the portfolio and taking proactive action for loss control measures.
- Interacting, coordination & collaboration with product, actuarial/ U/W team for review/follow up and finalizing underwriting guidelines for all types of health products (need based).
- Close coordination with claims COE team and conduct medical data analytics, reporting for the stakeholders like (department head, management committee, regulator, IIB etc.) on defined intervals.
Functional/ Operational (20%):
- Leading a team handling claims, customer queries & complaints, claim notification & registration, reserving of claims, coordination, etc.
- Along with managing accident & health claims operations, the role will closely work with the product/business team to build service capabilities.
- TPA/OSP (overseas service provider) evaluation, empanelment & driving performance management strategies.
- Hospital & providers network management.
Supervision and medical review of high loss health indemnity, critical illness claims, death claims.
People (20%):
Drive a culture of performance- 20 %:
- Provide support and guidance to health claims processors & networking team.
- Set goals, review findings and provide feedback to ensure a motivated and committed team works together to drive better results.
- Foster an environment of learning, excellence and innovation within all aspects of teamwork in the department
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