General Manager- Claims Operations

PRINCIPAL ACCOUNTABILITIES:-

• Leadership and Guidance: Provide expertise and direction to the cashless and reimbursement claims team, drawing upon extensive insurance knowledge to enhance team performance and service delivery.
• Manage the end-to-end operations for Claims: Manage daily operations for both Cashless and Reimbursement. The focus will be on daily productivity, efficiency improvement, process improvement, team adherence, and SLA adherence with partners. 
• Transaction Management: Oversee and monitor daily transactions related to claims processing, ensuring adherence to quality standards and operational efficiency as the claims leader.
• Product improvement: Design process changes required to improve efficiency via automation, process re-engineering etc. Lias with the Plum product team for getting these implemented.
• Knowledge Sharing: Promote a culture of knowledge sharing across cross-functional teams, simplifying the payout process and educating stakeholders on claims procedures and best practices.
• Error  Resolution: Identify processing errors by TPA & insure and raise them swiftly and get them fixed. Act as an advocate for customers by disputing grey area claims with insurers, utilizing a thorough knowledge of insurance terms and conditions to drive favourable outcomes. Raise disputes for decisions regarding medical understanding or terms interpretation, document gaps etc. and help the Duispute team with all relevant details. 
• Performance Transparency: Assist clients in understanding claims performance and service statistics regularly, enhancing transparency and trust in the claims process.
• Data Analysis and Process Improvement: Engage in continuous data analysis to identify trends and inefficiencies in the claims process, implementing improvements to enhance quality, efficiency, and overall service delivery.

INTERACTIONS:-

• Internal-
Endorsement team
Onboarding team
Products & Engineering
Other Claims teams
Support Inbound
Account Management


• External-
Insurance Companies
TPA claims processing or CRM teams 

Who can apply?

• 15 years of experience required in health insurance- either in an Indian or International insurer. A minimum of Claims operations experience with 8-10yrs in health claims 
• Bachelor’s degree in Business, Insurance, or a related field
• Extensive experience in Health Insurance claims management/operations, particularly in cashless and reimbursement claims. 
• Strong analytical skills with a proven ability to conduct detailed case analyses and data-driven decision-making.
• Excellent communication and interpersonal skills, facilitating effective collaboration with internal teams and external partners.
• A strong understanding of insurance policies, terms, and conditions, with experience in dispute resolution.
• Proven leadership skills, with a focus on developing and motivating teams for high performance.