Key Responsibilities

Quality Assurance

<ul>
<li style="margin-left:0px;">Develop and implement quality control frameworks for health claims processing.</li>
</ul>

<ul>
<li style="margin-left:0px;">Monitor and audit claims to ensure accuracy, compliance, and timeliness.</li>
</ul>

<ul>
<li style="margin-left:0px;">Identify root causes of errors and lead corrective action plans.</li>
</ul>

<ul>
<li style="margin-left:0px;">Collaborate with training teams to address knowledge gaps and improve performance.</li>
</ul>

Process Management

<ul>
<li style="margin-left:0px;">Apply Lean Six Sigma principles to identify and eliminate waste, reduce variation, and improve process efficiency.</li>
</ul>

<ul>
<li style="margin-left:0px;">Lead DMAIC (Define, Measure, Analyse, Improve, Control) projects to optimize claims workflows.</li>
</ul>

<ul>
<li style="margin-left:0px;">Conduct Value Stream Mapping and Failure Mode and Effects Analysis (FMEA) to assess process risks and opportunities.</li>
</ul>

<ul>
<li style="margin-left:0px;">Design and implement standardized operating procedures (SOPs) aligned with Six Sigma best practices.</li>
</ul>

<ul>
<li style="margin-left:0px;">Coordinate with IT and automation teams to enhance system capabilities and support process digitization.</li>
</ul>

Compliance &amp; Risk

<ul>
<li style="margin-left:0px;">Ensure adherence to regulatory requirements (IRDAI, HIPAA, etc.).</li>
</ul>

<ul>
<li style="margin-left:0px;">Maintain documentation for audits and regulatory inspections.</li>
</ul>

<ul>
<li style="margin-left:0px;">Monitor risk indicators and escalate potential issues proactively.</li>
</ul>

Stakeholder Collaboration

<ul>
<li style="margin-left:0px;">Work closely with claims processors, medical review teams, and customer service.</li>
</ul>

<ul>
<li style="margin-left:0px;">Liaise with external partners such as TPAs, hospitals.</li>
</ul>

<ul>
<li style="margin-left:0px;">Present performance metrics and improvement plans to senior leadership.</li>
</ul>

Key Performance Indicators (KPIs)

<ul>
<li style="margin-left:0px;">Claims accuracy rate</li>
</ul>

<ul>
<li style="margin-left:0px;">Turnaround time (TAT) improvement</li>
</ul>

<ul>
<li style="margin-left:0px;">Reduction in rework and escalations</li>
</ul>

<ul>
<li style="margin-left:0px;">Compliance audit scores</li>
</ul>

<ul>
<li style="margin-left:0px;">Process improvement ROI</li>
</ul>

<ul>
<li style="margin-left:0px;">Number and impact of Lean Six Sigma projects completed</li>
</ul>

Qualifications &amp; SkillsEducation &amp; Certifications

<ul>
<li style="margin-left:0px;">Bachelors degree in healthcare administration, Business, Engineering, or related field</li>
</ul>

<ul>
<li style="margin-left:0px;">Lean Six Sigma Green Belt certification required; Black Belt preferred</li>
</ul>

<ul>
<li style="margin-left:0px;">Additional certifications in quality management (e.g., ISO, TQM) are a plus</li>
</ul>

Skills

<ul>
<li style="margin-left:0px;">Strong knowledge of health claims lifecycle and adjudication processes</li>
</ul>

<ul>
<li style="margin-left:0px;">Proficiency in Lean Six Sigma tools: SIPOC, Fishbone Diagram, Control Charts, Pareto Analysis, etc.</li>
</ul>

<ul>
<li style="margin-left:0px;">Advanced data analysis skills using Excel, Power BI, or statistical software</li>
</ul>

<ul>
<li style="margin-left:0px;">Experience leading cross-functional process improvement projects</li>
</ul>

<ul>
<li style="margin-left:0px;">Excellent communication, leadership, and stakeholder management skills</li>
</ul>

Preferred

<ul>
<li style="margin-left:0px;">Experience with digital claims platforms and automation tools</li>
</ul>

<ul>
<li style="margin-left:0px;">Familiarity with Indian health insurance regulations and global best practices</li>
</ul>

<ul>
<li style="margin-left:0px;">Ability to thrive in a fast-paced, high-volume environment </li>
</ul>

Performance Management

Key Responsibilities Quality Assurance Develop and implement quality control frameworks for health claims processing. Monitor and audit claims to ensure accuracy, compliance, and timeliness. Identify root causes of errors and lead corrective action plans. Collaborate with training teams to address knowledge gaps and improve performance. Process Management Apply Lean Six Sigma principles to identify and eliminate waste, reduce variation, and improve process efficiency. Lead DMAIC (Define, Measure, Analyse, Improve, Control) projects to optimize claims workflows. Conduct Value Stream Mapping and Failure Mode and Effects Analysis (FMEA) to assess process risks and opportunities. Design and implement standardized operating procedures (SOPs) aligned with Six Sigma best practices. Coordinate with IT and automation teams to enhance system capabilities and support process digitization. Compliance &amp; Risk Ensure adherence to regulatory requirements (IRDAI, HIPAA, etc.). Maintain documentation for audits and regulatory inspections. Monitor risk indicators and escalate potential issues proactively. Stakeholder Collaboration Work closely with claims processors, medical review teams, and customer service. Liaise with external partners such as TPAs, hospitals. Present performance metrics and improvement plans to senior leadership. Key Performance Indicators (KPIs) Claims accuracy rate Turnaround time (TAT) improvement Reduction in rework and escalations Compliance audit scores Process improvement ROI Number and impact of Lean Six Sigma projects completed Qualifications &amp; SkillsEducation &amp; Certifications Bachelors degree in healthcare administration, Business, Engineering, or related field Lean Six Sigma Green Belt certification required; Black Belt preferred Additional certifications in quality management (e.g., ISO, TQM) are a plus Skills Strong knowledge of health claims lifecycle and adjudication processes Proficiency in Lean Six Sigma tools: SIPOC, Fishbone Diagram, Control Charts, Pareto Analysis, etc. Advanced data analysis skills using Excel, Power BI, or statistical software Experience leading cross-functional process improvement projects Excellent communication, leadership, and stakeholder management skills Preferred Experience with digital claims platforms and automation tools Familiarity with Indian health insurance regulations and global best practices Ability to thrive in a fast-paced, high-volume environment

Performance Management in Pune (UID-13870)

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