TM-FWA(Banglore)

Job Description

` Annexure I : ABG Job Description Template ` HayGroup Job Description Template 2017 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 22nd March 2024 ` Annexure I : ABG Job Description Template ` HayGroup Job Description Template 2017 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 ` Annexure I : ABG Job Description Template ` HayGroup Job Description Template 2017 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) 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 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 ` Annexure I : ABG Job Description Template ` HayGroup Job Description Template 2017 3. Vendor Management 4. Escalation & litigation 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 ` Annexure I : ABG Job Description Template ` 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. Head of FWA Dr Pankaj Srivastava Zonal manager South & East Central manager AM/DM - FWA Zonal manager North & west 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 Name Reports to – Manager Signature (needed for the hard Job Description Template 2017 HayGroup ` Annexure I : ABG Job Description Template ` copy) Job Description Template 2017 HayGroup

This opening is for the TM-FWA(Banglore) position in ABHI Cunningham Road.