PHI - Business Solution Specialist - Claims
Core
Design and implement a customer-centric Claims Management function and workflow for a greenfield health insurance deployment in India, focusing on automation, scalability, and productivity.
Role type
Senior Business Solution Specialist (Claims)
Builds
Digitally led claims management processes, auto-adjudication rules, and hospital empanelment workflows
Domain
Health Insurance / Claims Operations / Digital Transformation
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure
Required skills
End-to-end health insurance product knowledge, Claims process design, Business process mapping (BPMN), Requirements elicitation, Process impact analysis, UAT leadership, Fraud trigger creation, Tariff digitization, Stakeholder management
Preferred skills
Clinical knowledge, Creative problem solving, Consumer behavior understanding, Digital tool leverage
Technologies
BPMN, Data masters, Auto-adjudication systems, Hospital empanelment platforms
Responsibilities
Collaborate with cross-functional teams to co-create new claims processes and workflows; Identify process pain points and root causes to enhance efficiency; Review business process flow diagrams and ensure regulatory compliance; Lead testing and define acceptance criteria for claims systems; Execute plans for in-house claims process setup; Coordinate with partners (TPA/Agencies) for robust claims management.
Seniority
Senior, hands-on IC with team contribution