Team Member - Claim Control

Role overview

This position is focused on building and sustaining a strong claims control setup that supports compliance with regulations, quality checks, and reduction of risk across the claims lifecycle. It also strengthens governance through audits, fraud detection, and leakage control, while using MIS, analytics, and dashboards to turn data into practical decisions. A further part of the role is to improve processes continuously and support automation so claims operations become more efficient, transparent, and aligned with industry expectations.

Business and organizational details

Business: Financial Service - HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane, Maharashtra, India

Function: Services Operations

Reports to function: Financial Service Operations

Department: Ops - Claims

Reports to department: Ops - Claims

Employee designation: Team Member – Claims Control

Manager designation: Head – Claims Control

JD updated on: 20 Apr 2026

Job context and challenges

The health insurance market is highly competitive, with multiple private players competing for share while a large portion of business continues to renew with existing insurers. New business is therefore limited and must be won through sharper offerings, better customer understanding, and strong execution. The opportunity is especially significant in SME and startup segments, where demand is expanding quickly. The role sits in this environment and must help the organization capture more of the market through reliable controls, better reporting, and stronger operational discipline.

The wider market also faces changing customer expectations because of medical progress, lifestyle shifts, and evolving healthcare needs. Customers increasingly expect insurers to act as health advisors rather than only payers of claims. In this setting, the job must help maintain control standards while supporting tailored, efficient, and customer-relevant claims processes.

The company itself is positioned as a digital-first health insurer with a differentiated “Health Insurance for All” approach. The role contributes to that promise by ensuring backend claims processes are consistent, controlled, and seamless.

Challenges include:

• Publishing MIS, regulatory submissions, and analysis on a regular schedule while maintaining strong controls despite system and infrastructure limitations.
• Spotting trends and recommending actions for fraud and risk reduction within compliance and group policy boundaries.
• Preventing breaches in claims TATs and ensuring data is submitted on time, including manual workarounds when systems are constrained.

Key responsibilities

• Set up and maintain claims control frameworks, including SOPs, checklists, and monitoring routines.
• Ensure claims processing follows IRDAI rules, TAT requirements, policy wording, and internal standards.
• Run periodic claim quality audits, review high-value claims, and analyse exceptions.
• Identify fraud, leakage, and risk patterns, and propose preventive as well as detective controls.
• Create and maintain control MIS, dashboards, and analytical reports using Excel, SQL, or other applicable tools.
• Work on process simplification, automation, and system improvements by identifying gaps in the current control environment.

Requirements

• Strong understanding of claims operations and control mechanisms.
• Knowledge of regulatory compliance requirements, especially IRDAI norms and claims TAT rules.
• Ability to perform audits, exception reviews, and quality checks on claims files.
• Comfort with analysing data, identifying patterns, and drawing insights from reports.
• Hands-on capability in Excel and familiarity with SQL or similar analytical tools.
• Ability to recommend process improvements and support automation efforts.
• Capacity to work around operational constraints while maintaining accuracy and control.

About the company and role background

Aditya Birla Health Insurance Co. Limited was formed in 2015 as a joint venture between Aditya Birla Capital Limited and MMI Strategic Investments (Pty) Ltd, and began operations in October 2016. The company entered the health insurance market with the aim of serving a wider set of customers beyond traditionally targeted segments.

Its market approach is built around “Health Insurance for All” and is reflected in every customer touchpoint and backend process. The company’s offering includes a wellness-linked proposition, chronic care support for conditions such as diabetes, asthma, high cholesterol, and hypertension from day one, and a digital-first, paperless operating philosophy.

Additional information

Business workforce number: 7000

Unit workforce number: 7000

Function workforce number: 700

Department workforce number: 260

Direct reports: Not applicable

Relationships: No specific internal or external relationship details were provided.

Organizational relationships: Structure details above and below the role were not specified in the source.

Sign-off: The hard copy of the JD is to be signed by the job holder and the reporting manager and retained in organizational records.