ImpactGuru - Associate Vice President - Operations - Trust & Safety (10-15 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.

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.