Job Description
Job Purpose
Health data governance, standardization, structure, reconciliation and validation to maintain adequate quality of health data in EHR.
Examine complex data and turn it into information and insight to informed business decisions. Also monitor performance and quality control plans to identify any issues or ways to improve systems and database designs. This role requires collaborating with database developers to implement effective automation processes by developing access queries so data can be mined for quality control and accuracy. This role suits people who enjoy working with numbers and data sets, have an aptitude for computer systems and software, and have strong analytical abilities.
Job Context & Major Challenges
Job Context & Challenges:Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016.ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6th entrant in a category with well-established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of Health Insurance for All, a one of a kind proposition in India at the moment. This is a philosophy that is being built through every single consumer touch point and into every single backend process of the company to ensure a customer's experience of our proposition is continuous and seamless.
ABHI's unique offering to market includes proposition includes -
A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1
ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.
ABHICL's vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.
Co-operation from stakeholders in timely execution of Risk Actionable & Internal audit (including sharing of data requirement to management response for closure of audit report)
Key Challenges for the role –
Knowledge of Claims processes: Indemnity (Cashless, Reimbursement), Fixed Benefit Products
Understanding of Claims systems (process flow & System fields) – Health, PA & Travel
Experience in measurement of performance (TAT, accuracy in claims adjudication)
Expectations management of the Claims team
TAT & expectations management for specialized business handling.
Ensure uniformity in quality & maintain TATs of Claims decisions
Create & maintain standards/protocols for Claims team
Audit claims decisions in adherence & compliance with the Claims guidelines, uniformity in decisions, and approval authority limits (In house and TPA claims)
Periodic portfolio analysis: profitability (loss ratio / combined ratio), analyze frequency and severity, medical inflation
Maintain a consistent service delivery to ensure client retention and satisfaction
Identify risks to the company and escalate accordingly
Execution of processes and projects –operations, to be in line with defined standards
Inputs for refinement and development of claims guidelines, policies, and procedures.
Publishing Quality analysis with Claims Team and sharing a positive feedback
Key Result Areas
KRA (Accountabilities) (Max 1325 Characters)Supporting Actions (Max 1325 Characters)
KRA1 5-10% health data audit from all digitization partner Interpret data and analyze the results using statistical techniques. Provide ongoing reports on the effects of different strategies and observe any trends or issues to raise with reporting manager.
KRA2 Create analytic report to support health outcomes This role involves working with database developers to implement databases for more effective data collection and storage, as well as performing data analytics and other strategies to optimize the efficiency and quality of the data being collected.
KRA3 Organize monthly MIS report and streamline ADHOC data requirement Acquire data from primary or secondary data sources to maintain database systems. They also identify and interpret trends or patterns in complex data sets.
KRA4 WellbeingScore health data validation and reconciliation This role involves filtering and cleaning data by reviewing clinical reports and performance indicators to correct any digitization error and check the efficiency of the clinical data collection processes in place.
Work with management to prioritize business and information needs and identify new processes that will improve the systems in place and define new opportunities.
