Lead - Health Claims - Document Verification

Digit Insurance

Website: godigit.com
Job details:
Job Description

Team Lead – DV

Department: Health

Sub-Department: Health Claims

Grade: G3C

Reporting To: Head – Health Claim Operations

Prepared By: HRBP

Consulted With: Lead – DV

Position Description

The Lead – DV is responsible for managing end‑to‑end health insurance claims operations for the DV function. This role involves leading a team of claims associates, ensuring accuracy, compliance, and timely claim processing while consistently meeting SLAs and quality benchmarks. The role also serves as a key point of escalation, drives continuous process improvement, and collaborates with TPAs, hospitals, and internal stakeholders to ensure smooth and compliant claim operations.

Key Responsibilities

• Lead, mentor, and support a team of claims associates to drive productivity, accuracy, and SLA adherence.
• Oversee correct registration, triaging, and processing of health insurance claims as per policy terms, SOPs, and internal guidelines.
• Ensure compliance with IRDAI regulations, internal control frameworks, and audit standards.
• Review complex claims and handle escalated customer or provider issues to ensure timely and effective resolution.
• Monitor claim quality and documentation standards, ensuring complete, accurate, and clear case notes in the system.
• Support MIS and reporting by identifying and highlighting trends related to pendency, rejections, rework, and repeat issues.
• Identify operational gaps and contribute to process improvements to enhance efficiency, accuracy, and customer experience.
• Coordinate with TPAs, hospitals, and cross‑functional internal teams to address operational dependencies and resolve issues.
  
  

Experience

Experience & Skills Required

• 8–15 years of experience in health insurance or TPA operations.
• Prior experience in claims processing or pre‑authorization operations is required
• Experience handling provider queries, escalations, and medical documentation review
  
  

Technical Skills

• Strong understanding of health insurance claims processes, policy interpretation, and SOP adherence.
• Familiarity with regulatory requirements, including IRDAI guidelines.
• Ability to analyze claim trends and operational data for MIS and reporting.
• Working knowledge of claims management systems and workflows.
• Proficiency in MS Office tools.
  
  

Behavioral Skills

• Attention to Detail
• Effective Communication
• Collaboration and Stakeholder Management
• Ownership and Problem Solving
  
  

Qualifications

• Graduate degree in any discipline.
• No specific academic stream required.
• No mandatory certifications.
  
  

What You Bring to Digit

• Proven leadership capability in managing claims teams and operational performance.
• Strong decision‑making skills with a balanced focus on compliance and customer experience.
• Ability to drive accountability, coach teams, and manage escalations effectively.
• A continuous improvement mindset with the ability to identify risks and streamline processes.

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