Chief Medical Officer - Accident & Health Claims

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