Impact Guru - AVP - Operations/Trust & Safety - CarePal (15-20 yrs)

Job Title: AVP Operations Trust & Safety.

Company: CarePal Group.

Location: Mumbai, India.

Department: Trust & Safety.

Reports To: CEO.

About CarePal Group:

- CarePal Group is transforming healthcare financing in India by providing cutting-edge solutions that make critical and elective treatments more accessible and affordable.

- Through our platforms-Impact Guru (for medical crowdfunding), CarePal Secure (an insurance and benefits marketplace), and CarePal Money (a healthcare lending marketplace)-we aim to touch one million lives by 2030, empowering people with financial tools to secure essential healthcare.

- In September 2024, CarePal Group was recognized at the Economic Times Healthcare Awards for 'Excellence in Affordable Healthcare Financing.

Impact Guru, our medical crowdfunding platform, has also garnered multiple honors, including:

- TechCircle 2018 Public Choice Award for Best Social Impact Startup.

- ET Intelligent Health & Tech Awards 2020 for Best Technology Solution for Social Good.

- Best Healthtech and Health Financing Brand by IHW Council.

The founders of the CarePal Group are: Piyush Jain, Khushboo Jain & Vikas Kaul

Job Summary:

- The AVP of Operations Trust & Safety will drive CarePal Group's trust and safety strategy, overseeing hospital coordination, insurance claim processing, and TPA (Third-Party Administrator) operations.

- The role demands a strong experience in setting and running processes in the healthcare insurance domain, including patient admission and discharge, billing verification, risk mitigation, and fraud prevention.

- The successful candidate will be a strategic and hands-on leader, ensuring that trust and safety standards are met consistently across operations.

Key Responsibilities:

Hospital Coordination:

- Manage relationships with hospital billing departments to ensure seamless service coordination.

- Oversee admission, discharge, and cost verification processes, ensuring adherence to CarePal's pricing agreements.

- Lead efforts to streamline billing accuracy, end to end claim processing, optimize reconciliation processes, and enhance the patient experience.

Billing Verification & Reconciliation:

- Conduct cost verification and reconciliation with hospital billing & Finance teams to prevent discrepancies and ensure adherence to agreed rates.

- Develop structured reconciliation processes to accurately track and validate patient costs.

- Identify opportunities for cost-saving and process improvement in billing workflows.

- Patient Journey & Health Insurance Coordination.

- Oversee the full patient journey from admission through discharge, ensuring compliance with healthcare insurance guidelines.

- Coordinate with TPA and hospital teams for seamless admission, discharge, and insurance claim processes.

- Ensure all insurance-related processes are efficient, accurate, and meet regulatory standards.

Patient Background Verification:

- Manage patient background verification processes, ensuring accurate information validation.

- Implement standardized procedures for patient verification, proactively identifying and resolving discrepancies.

- Maintain high standards of trust and safety by ensuring complete and accurate patient onboarding till claim settlement.

TPA Operations & Insurance Claim Management:

- Lead TPA operations, focusing on claims processing, insurance documentation, and patient eligibility verification.

- Collaborate with TPA providers and insurance companies to ensure streamlined workflows and compliance.

- Enhance TPA operations by optimizing processes, reducing processing times, and improving patient satisfaction.

Fraud Prevention & Risk Management:

- Oversee insurance claim processes, implementing fraud detection and prevention strategies.

- Regularly monitor and audit for fraud risks, addressing any detected anomalies.

- Maintain high standards of trust by managing systems that prevent fraudulent activities in patient billing and insurance claims.

Policy Development & Compliance:

- Develop policies to uphold trust and safety in patient operations, aligning with healthcare and insurance standards.

- Regularly update policies to comply with regulatory changes and industry trends.

- Ensure strict adherence to data privacy laws, healthcare regulations, and insurance guidelines across all operations.

Risk Analysis & Escalation Management:

- Conduct risk assessments to identify potential issues, especially in hospital coordination, TPA processes, and patient verification.

- Lead escalation protocols to resolve trust and safety concerns promptly in collaboration with hospital and insurance partners.

- Regularly review processes to minimize risk and maintain high standards of operational integrity.

Data Analysis & Reporting:

- Utilize data analytics to track operational trends, identify areas for improvement, and monitor patient satisfaction.

- Prepare regular reports on trust and safety metrics, incident outcomes, and fraud prevention results for executive leadership.

- Use data insights to refine processes, enhance efficiency, and guide strategic decision-making.

Team Leadership & Development:

- Lead and mentor the Trust & Safety team, fostering a culture of accountability, integrity, and excellence.

- Ensure team members are well-trained in trust and safety protocols, billing verification, and insurance claims processes.

- Set clear objectives, conduct performance reviews, and support professional growth within the team.

Qualifications:

- Bachelor's degree in healthcare management, business administration, or a related field.

- MBA or equivalent advanced degree preferred.

- 10+ years of experience in Health Insurance, claim processing, with a focus on TPA management, hospital coordination, and billing.

- Demonstrated success in managing healthcare insurance claims, billing verification, and trust and safety protocols.

- Strong expertise in healthcare insurance operations, fraud prevention, risk management, and regulatory compliance.

- Proven leadership skills, with experience managing cross-functional teams and optimizing complex operational workflows.

- Excellent communication, negotiation, and stakeholder management abilities.