Head – Claims, FWA and Retail UW

Lead - Claim QC & Audit, Case Management

Department: Claims

Designation of the Manager: Head – Claims, FWA and Retail UW

Location: Thane (Onsite)

The role is responsible for ensuring accuracy, compliance, and quality in claims processing across

both inhouse and TPA units. It involves concurrent and retrospective audits of cashless and

reimbursement claims, covering indemnity and fixed benefit types. The position safeguards process

integrity by identifying errors, mitigating risks, and driving corrective actions, while strengthening

governance, compliance, and customer trust.

• Claims Quality Check

Quality check of processed claims Inhouse+ TPA (Concurrent/ Retrospective audit)

Processing Unit - Inhouse and TPA Cashless and Reimbursement Benefit Type - Indemnity

and fix benefit Review of FWA closure quality Sample investigation of send back claims.

• High value Audit of Cashless & Reimbursement Claim

100% review of Claim with amount as below Indemnity claims above 5 Lakh Fix benefit

above 20 Lakh Early claims within 1-2 team policy inception (New business/Port) Review of

UW policy impact on claims Review of Product benefit on claim incidence rate Review of

System related rules & validation Audit of NEFT/Payment process Assess compliance with the

latest industry standards and regulations Audit of Clinical coding for accurate system

adjudication and data analytics Boost documentation and reporting accuracy

• Review of Tarrif & Identify abuse and renegotiation of tarrif

Review of Provider tariff Review of Non package illness and help provider team for creation

of packages. Review of existing packages, identify abuse and renegotiation