# Manager- Claims Management

**Company**: Prudential Health India
**Location**: Mumbai
**Work arrangement**: onsite
**Experience**: senior
**Job type**: full-time
**Category**: Operations
**Industry**: Healthcare

**Apply**: https://prudential.wd3.myworkdayjobs.com/en-US/prudential/job/Mumbai/PHI---Manager--Claims-Management_25090174?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/jobs/job_335beebf-fe4

## Description

Prudential Health India is seeking a Manager – Claims Management to join our Experience team in Mumbai.

As a Manager Claims, you will guide the processing team by providing medical opinions for Health Insurance Claims, ensure claims are settled according to company practices and procedures, and process and approve medical claims.

Key responsibilities include:

- Guiding the processing team by providing medical opinions for Health Insurance Claims

- Ensuring claims are settled according to company practices and procedures

- Processing and approving medical claims pertaining to Indemnity, Benefit for both Group and Retail

- Managing and maintaining data of referred cases, savings achieved, and impact against cashless outgo

- Creating detailed standard operating processes for seamless functioning of claims adjudication

- Auditing TPA processed claims and in-house processed claims

- Providing medical decisioning and guidance to the team

- Preparing dashboards to manage TAT, cost vectors, loss ratios, and regional distribution

- Supporting the Group UW team for providing claims analytic input

- Ensuring regulatory compliances and timely implementation of new circulars

- Managing litigation cases and providing input and evidence in SCN

- Training TPA teams on new benefits, process changes, and claim philosophy

- Collaborating with FWA Manager to provide inputs from agencies for efficient fraud restriction

- Setting up and creating robust governance to manage TPA processes

Requirements:

- MBBS preferred / BAMS / BHMS / BDS

- 7-10 years of experience in health insurance claims management with at least 2-3 years in a manager role

- Understanding of the TPA ecosystem and experience in managing TPA models

- Startup experience or setting up a team from scratch (preferred)

- Decisive and creative individual with good judgment and analytical skills

- Excellent verbal and written communication skills and strong negotiation skills

## Skills

### Required
- Health Insurance Claims Management
- Medical Opinion
- Claims Adjudication
- Regulatory Compliance
- Data Analysis

### Nice to have
- TPA Ecosystem
- Startup Experience
- Team Management
- Clinical Knowledge

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Source: [Apply at prudential.wd3.myworkdayjobs.com](https://prudential.wd3.myworkdayjobs.com/en-US/prudential/job/Mumbai/PHI---Manager--Claims-Management_25090174?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)