Business Solution Specialist - Claims

We are looking for a talented Business Solution Specialist - Claims to partner with us in our mission to make Indians healthier. As a Business Solution Specialist, your typical week might include collaborating with cross-functional workstreams for new products, processes, testing, and implementation.

Responsibilities:

• Collaborate and co-create with cross-functional workstreams for new products, processes, testing, and implementation.
• Ensure that processes and technologies are designed to focus on automation, scalability, and productivity.
• Develop in-depth understanding of business processes, articulate use-cases, user-stories, and requirement documents/change requests for identified features/capabilities for applicable platforms and projects.
• Collaborate with functions including Technology, Product & Actuarial, Claims, Compliance, Risk Management, and Finance.
• Review business process flow diagrams with Business Analyst to ensure comprehensive documentation.
• Identify pain points, bottlenecks, redundancies, delays, errors, or any other areas to enhance the process.
• Check if the current process complies with relevant regulations and industry standards.
• Review techniques such as flowcharts, BPMN diagrams, or process maps to illustrate the sequence of activities.
• Undertake iterations in signed-off Business Process Flow, when required, in collaboration with stakeholders to refine and finalize the next version.
• Perform process impact analysis across various platforms, holding an end-to-end view of user journeys.
• Ensure that acceptance criteria are defined and met.
• Lead testing in collaboration with functional users.
• Continuous enhancement of Overall Rules for Allocation, Auto Adjudication, Data masters, fraud trigger creation, and implementation for claims management process.
• Ensure 100% Tariff digitization for direct empanelment hospitals and preferred network.
• Coordination with relevant partners (TPA/Agencies) required for robust digitally led claims management process.
• Collaborate with relevant stakeholders, management Design, and execute staggered plan for 'Inhouse' Claims Process setup by Y3.

Requirements:

• At least 10 years of total experience in health insurance functions and 3-5 years' experience in Health Claims insurance.
• End-to-end knowledge of health insurance products, operations processes, and technology systems.
• Ability to understand high-level processes and convert them into detailed business requirement documents.
• Proven track record of end-to-end implementation and business outcome delivery of significant insurance systems.
• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills and strong negotiation skills.
• Ability to thrive in environments that celebrate co-creation and collaboration.
• High resilience – ability to manage yourself, your teams, and your peers when faced with ambiguity or failure.