TagLynk Careers, hiring partner for a leading insurance organization, is looking for a senior leader to drive Accident & Health Claims Strategy & Operations. This role is ideal for seasoned professionals with deep expertise in health insurance claims, fraud mitigation, provider network management and regulatory compliance.
Key Responsibilities
Strategic Leadership
- Build and drive end-to-end Accident & Health Claims strategy, frameworks and processes.
- Ensure compliance with latest health insurance regulations; implement process refinements.
- Lead the move towards paperless, automated claims settlement with superior TAT & customer experience.
- Design and monitor performance metrics for TPAs and internal claims teams.
- Collaborate with technology teams to build/enhance claims systems & automation.
- Build strong partnerships with external stakeholders: TPAs, investigators, hospitals, OSPs, providers.
- Drive continuous improvement, best practices, and customer-first delivery.
Financial & Risk Management
- Partner with audit & fraud teams to implement fraud prevention and loss-mitigation frameworks.
- Manage claims budgets, average claims cost and cost-containment initiatives.
- Analyze ICR, medical data and portfolio trends; drive proactive risk control.
- Support product, U/W and actuarial teams with insights for guideline finalization.
- Lead periodic reporting for internal & regulatory stakeholders.
Functional & Operational Excellence
- Lead teams managing claims processing, customer queries, complaints, reserving & registration.
- Oversee adjudication of complex claims: indemnity, critical illness, accidental death.
- Manage network providers, evaluate & empanel TPAs/OSPs, drive performance management.
- Partner closely with product/business teams to strengthen service capability.
People Leadership
- Drive a culture of accountability, high performance and continuous learning.
- Set goals, mentor teams, review performance, and build future leaders in claims operations.
- Strengthen collaboration across cross-functional internal teams.
Desired Profile
- MBBS / BAMS / BHMS / B.Pharm preferred; or any graduate with health insurance certifications.
- 1520 years of experience in health insurance / TPA / wellness / healthcare domains.
- Strong exposure to claims operations, adjudication, medical review, fraud control, underwriting basics, hospital administration, and provider network management.
- Proven leadership in handling large teams and multi-stakeholder environments.
- Excellent analytical, communication, negotiation and people management skills.
Key Stakeholders
Internal: Product, U/W, Distribution, Customer Service, Technology, Compliance, Finance
External: TPAs, Hospitals, Investigators, Providers, Corporates, Customers
