Manager - FWA

Job Description

Basic Details:

Fill the required information about business, unit, location, position, reports to position and date of updation of JD

Business

Financial Service - HO

Unit

Aditya Birla Health Insurance Company Ltd

Location

Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)

AM/DM

Reports to: Poornata Position Title

Manager

Function

Services Operations

Reports to: Function

Services Operations

Department

Ops - FWA

Reports to: Department

Ops - FWA

Designation of the Employee

Manager – Ops- FWA

Designation of the Manager

Zonal / Central Manager – Ops - FWA

Date of writing/updation of JD

22

nd

March 2024

1) Position purpose:

Write the purpose for which the job exists (in 2-3 lines)

(Max 1325 Characters)

The purpose of this role includes

1.To do investigation of the cases referred to FWA group, do the quality check of cases referred to investigation and at additional observation point for investigation allocate case to vendor in a given TAT and take follow up with vendor to cover 3- 5 parameter along with assisting investigation documents which will help in taking final decision on claim. Payable/rejection, query).

FWA manager need to also monitor closely to vendor on quality of investigation, parameters covered during investigation, evidences collected during investigation. Adherence to investigation TAT, vendor involvement with nexus are giving wrong report. In branch level they also need to observe FLS, local hospitals, vendors, clients, sales manager, provider manager involved in any fraudulent activity and same need to be reported to zonal manager and vertical manager.

2) Dimensions:

Mention quantitative or qualitative parameters that are relevant for the job and deliver a better understanding of the scope and scale of the job.

Business Workforce Number

(Max 254 Characters)

On Roll – 6000+

Offroll/ Part time – 4000+

Unit Workforce Number

(Max 254 Characters)

On Roll – 6000

Offroll/ Part time – 4000+

Function Workforce Number

(Max 254 Characters)

On Roll – 800

Offroll/ Part time - 279

Department Workforce Number

(Max 254 Characters)

On roll – 29

Off roll - 2

Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Clients or any other parameter

3) Position context & Key challenges: Write the specific aspects of the job that deliver a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters)

1) Once the claim verification request is received from company, QC manager will study the claim, make additional triggers, refines triggers, to form customize questionnaire according to trigger, to allocate the claim for field investigation.

2) To monitor activity of field officers, to guide them and to get the claim investigated according to trigger and as per protocol, to take daily and timely updates, to sustain updates in our data.

3) To verify/ evaluates evidence collected by field officers, to guide them if any rework is needed. Guide vendor to cover minimum 3 to 5 parameter (Insured, Hospital, treating Doctor, Lab & Pharmacy) as per case requirement during field investigation.

4) Collaborate with vendor, to make closure report as per format, to close the FWA in portal of ABHI, to update FWA Manager / Central OPS group through mail about closure of claim.

5) To monitor claims from allocation to closure and to sustain quality of investigation. As per given product TAT for investigation.

6) To deliver assignment in TAT, we need to oversee vendor smartly so that we need not to work on weekends and public holidays.

7) To sustain harmonious relationship with all managers in FWA, Claim, provider group, higher management staff in branch location, / clients/ Vendors/officer managers/assisting staff.

8) To sustain target of company, 95% TAT and 30% Success ratio, A grade quality evidence with minimal escalations, to sustain hygiene in document collection.

9) Confidentiality of work, Nature of work and insured's data base should be protected with utmost care. Digital work ethics like – keeping camera on while attending meeting, prior information about late joining, distraction at background while Microsoft Teams/ Digital/Virtual meet/ training

Challenges –

To execute all strategies, duties, efforts which increases business of company in ethical way.

a. To execute all those activities to cut down the claim cost of the company.

b. To identify, investigate and to report nexus/ fraud claims/ fraud advisor etc if any

c. To sustain data of all investigated cases, to identify fraud/ new fraud hospitals/ fraud pathologist/ fraud pharmacy/ fraud clients which will improves overall performance.

d. To sustain secrecy of our internal or external data.

e. No opinion/pro rejection/query cases discussion with Zonal Manager /Claim manager prior closure.

4) Core result areas: Write the key results expected from the job and the assisting actions for each of these core result areas (For a majority of jobs typically there could be 4- 7 core result areas)-

Maximum 10 KRAs can be updated

Core result areas (Max 1325 Characters)

Assisting Actions (Max 1325 Characters)

1.Investigation Portfolio Management - assigned Geography

2.Innovative Investigation practices & Fraud prevention measures

3. Vendor Management

4. Escalation & litigation

1.a) Portfolio Monitoring & Management.

1.b)Investigation performance w.r.t success rate & TAT 1.c)Look after quality of triggers , referrals & quality of investigation for better outcome.

1. d) Portfolio Impact in retail & group

2.a) Number of seeding activities carried out & Outcome

2.b) Number of fraud hospitals identified and DE panelled from the network

2.c) Insured / Advisor / Hospital Blacklisting

2.d) No. of policies recommended for cancellation

2.e) No. of policies tagged for renewal block

2.f) dummy cases to be investigated against investigator and report to be submitted

2.g) Project for suspected fraud location

2.h) no hospital infrastructure audit/month which resulted in to DEempanelment/blacklist/recovery etc.

3.a) Vendor development 3. b) Vendor Training

3.c) vendor performance monitoring

4.a) Escalation to next level

4.b) Cases present in Ombudsmen / litigation

5) Position purpose of Direct Reports: Describe the position purpose of the direct report/s to the job (in 2-3 lines for each report)

Loss minimization by rejecting non payable claims, improve client satisfaction by quick settlement of payable cases.

6) Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/group members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type (Max 80 Characters)

Frequency

Nature (Max 1325 Characters)

Internal

Claim Group

Underwriting group

Provider group

Market conduct group

Grievance group

Legal group

Daily Baisis

Case to case basis

Fortnightly basis

Monthly basis

As & when required

As & when required

For claim decision where difference of opinion

For policy termination

For de empanelment /blacklisting of providers

For involvement of internal employee and sales employee

As &on when post rejection when we receive escalation /grievance of the claim

As & on when case gone in legal forum

External

NA

7) Organizational Relationships: Deliver the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Deliver the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)

This opening is for the Manager - FWA position in ABHI Mukherjee Road.