Claims Head Health Insurance

Claims Head — Health Insurance

Location: Mumbai (Goregaon West)

Experience: Required 5+ years in health insurance claims

Department: Claims & Customer Experience

Employment Type: Full-time

About Us

We are a health-focused platform committed to simplifying the insurance and healthcare experience for customers. We aim to provide customers with transparent, responsive, and hassle-free support throughout their health insurance journey — especially during claims.

About the Role

As Claims Head, you will take end-to-end ownership of the health insurance claims process — from intimation through to final settlement and closure. You'll manage relationships with insurance companies, TPAs, and hospitals, lead a claims team, and act as the primary escalation point for complex or high-value cases. This is a high-impact role at the intersection of operations, relationship management, and customer experience, directly shaping how customers experience one of the most stressful moments of their healthcare journey.

Key Responsibilities

End-to-End Claims Management

•       Own the complete health insurance claims lifecycle across cashless and reimbursement claims.

•       Monitor claims from intimation through documentation, assessment, approval/rejection, settlement, and closure.

•       Ensure claims are processed within applicable turnaround times (TATs).

•       Review pending, delayed, rejected, and disputed claims, and drive corrective action.

•       Develop SOPs and processes for efficient, consistent claims handling.

Claims Kavach (Proactive Customer Support)

•       Lead our proactive claims-assistance initiative, offering proactive support during hospitalization and claims.

•       Help customers understand the claims process, documentation needs, and policy coverage.

•       Guide customers through cashless approvals, queries, deductions, rejections, and settlements.

•       Identify potential claim issues early and intervene before they escalate.

•       Partner with the IT & Product teams on automation and building an integrated claims system.

Insurer, TPA & Hospital Coordination

•       Manage coordination with insurers, TPAs, and hospitals for smooth, timely claims processing.

•       Coordinate cashless approvals, enhancements, queries, deductions, rejections, and settlements.

•       Build and maintain strong working relationships with key insurer, TPA, and hospital contacts.

Escalation Management

•       Own all critical and high-priority claim escalations, building a structured escalation matrix.

•       Personally intervene in high-value, sensitive, or delayed claims and track them to closure.

•       Conduct root-cause analysis on escalations and implement preventive measures.

Claims Quality & Audit

•       Review claim decisions, deductions, rejections, and repudiations for accuracy and compliance.

•       Conduct regular quality audits and build claim-quality dashboards and MIS reports.

•       Track insurer/TPA-wise rejection and deduction trends, plus claims and loss ratios.

Team Management

•       Build, manage, and mentor the claims team; allocate work by priority, complexity, and capability.

•       Set KPIs, run performance reviews, and train the team on policies, process, and escalations.

•       Foster a customer-first culture within the claims function.

Customer Experience

•       Ensure a smooth, transparent claims journey and act as a single point of coordination.

•       Personally handle sensitive or high-value customer cases.

•       Track and improve claims CSAT and resolution TAT.

MIS, Analytics & Reporting

•       Maintain regular claims MIS: volumes, ageing, TAT, deductions, rejection reasons, and more.

•       Report insurer-wise and TPA-wise performance, hospital-wise issues, and escalation ageing.

•       Track customer complaints, resolution TAT, and overall Claims Kavach performance.

What We're Looking For

Education

•       Graduate / Postgraduate in any relevant discipline.

•       Insurance qualifications (Licentiate / Associate / Fellow of Insurance Institute of India) are a plus.

Experience

•       5+ years of experience in health insurance claims.

•       Hands-on experience with both cashless and reimbursement claims, with a solid grasp of inclusions and exclusions across health products.

•       Experience working directly with insurance companies, TPAs, and hospitals.

•       Prior experience managing a claims team is preferred.

•       Background in a broker, insurer, TPA, health-tech, or insurance distribution organization is an advantage.

•       Familiarity with technology, AI, and process automation.

Skills

•       Strong knowledge of health insurance claims and policy terms — exclusions, waiting periods, deductibles, co-pay, room-rent limits, etc.

•       Strong insurer and TPA relationship-management skills.

•       Excellent escalation management, negotiation, and problem-solving ability.

•       Excellent communication skills and a customer-centric approach.

•       Strong analytical and MIS skills.

•       Ability to manage high-pressure, time-sensitive situations.

•       Strong team leadership and people-management skills.

Why Join Us

You'll play a central role in our mission: ensuring every customer receives timely, transparent, and effective support when they need to use their health insurance the most.