Assistant Vice President- Claims

JOB DESCRIPTION

PURPOSE OF ROLE

• Providing operational leadership to the Central Operations function ensuring quality, productivity, utilization of
• manpower and adherence to SLA.
• Designation AVP- Central Operations
• Function Central Operations - Supervisor
• Location Bangalore
• Educational Qualification MBA / Any IT Professional / BAMS / BHMS / MBBS
• Industry Type TPA / Insurance / Healthcare

Roles and Responsibilities

Claims Processing Metrics

• Claims Settlement Cycle Time: Average days from claim receipt to

payment, targeting quick resolution to enhance member satisfaction

• Claims Denial Rate: Percentage of claims rejected, indicating

adjudication accuracy and policy compliance.

• Claims Processed Per Employee: Volume handled per staff member,

measuring operational productivity.

Financial and Efficiency Metrics

• Medical Loss Ratio (MLR): Portion of premiums spent on claims,

ensuring balanced financial health.

• Cost per Claim: Total expenses per processed claim, optimizing

resource use.

• Operational Efficiency Rate: Ratio of value-added work to total

efforts, aiming for 85-90%

• Profit & Loss (P&L) responsibilities and ensure adherence to the

• Annual Operating Plan (AOP) for Operations (both hubs and central
• operations). Role will now include overseeing staffing requirements for
• all hubs and central teams, further strengthening operational
• effectiveness across the function.
• Service and Compliance Metrics

• First Contact Resolution Rate: Percentage of issues resolved on initial

interaction for members or providers.

• Prior Authorization Response Time: Average minutes to respond to

pre-approval requests.

• SLA Compliance Rate: Adherence to service level agreements on

turnaround and accuracy.

• Implementation of claims operations strategy. Ensure people and

claims related processes are managed efficiently.

• Oversee distribution of claims work to the teams. Ensure

maintenance of quality and productivity standards at a high level.

• Improve process efficiency through business process re-engineering/

automation in order to process more claims with optimal resources.

• Monitor all the outstanding claims. Ensure outstanding claims do not

exceed 30 days.

Relevant Experience Strong experience in Central Operations / Branch Operations / Claims

processing in a TPA / Insurance

Total Experience 8-12 years with an insurance / hospital management experience

• Ability to advise and guide with appropriate Operational / finance /

medical knowledge to the team.

• Ability to handle team

Technical Competencies

Analytical Ability

• Operational Excellence
• Problem Solving & Decision Making

Behavioral competencies

Collaboration

• Communication
• People Management
• Stakeholder Management

Intertested candidates can share their profiles to varsha.malode@mediassist.in