Insurer Liaison Manager – Claims Resolution

About Job

Insurer Liaison Manager – Claims Resolution is a dedicated, on-ground role responsible for resolving complex and long-pending health insurance claims that cannot be closed through regular remote coordination with insurers.

The role is based full-time at the insurer's claims processing office and is specifically focused on claims that have breached TAT, remain unresolved beyond SLA, are stuck as escalations, or involve unique, grey-area, or high-level cashless cases. The Insurer Liaison Manager works directly with the insurer's processing and decision-making teams to drive these cases to closure.

The role requires strong knowledge of health insurance policy terms, conditions and medical terminology, along with a customer-first mindset. The role holder will be expected to deep-dive into complex claim scenarios, interpret policy and medical information accurately, and bring multiple stakeholders—including insurers, Plum Operations, clients/HR teams and hospitals—onto the same page to arrive at a fair, swift and well-reasoned resolution.

Role Responsibilities

• Manage TAT-Breached Claims: Take ownership of claims that have breached the agreed TAT and remain unresolved despite prior coordination between Plum's Claims Operations team and the insurer through email and calls. Drive these cases to closure through in-person coordination with the insurer.
• Resolve Disputed Cases: Handle cases that remain unresolved beyond SLA despite multiple rounds of remote follow-ups. Engage directly with the insurer's team to break deadlocks and drive a fair and final resolution.
• Drive Long-Pending Escalations: Prioritise escalations that have remained open for an extended period, engage the relevant insurer stakeholders in person, and ensure timely closure.
• Handle Unique / Grey-Area / High-Level Cashless Escalations: Work on cashless claims involving unclear policy interpretation, unusual case specifics, complex scenarios, or cases requiring senior insurer sign-off. Coordinate directly with the relevant processing and decision-making teams to resolve these cases.
• Apply Claims Interpretation with a Customer-First Mindset: Use in-depth knowledge of health insurance policy terms, conditions and medical terminology to interpret cases fairly and accurately, ensuring genuine claims are evaluated appropriately rather than rejected solely on technicalities or overly narrow interpretations of policy terms.
• Deep-Dive into Complex Claims: Review policy wording, medical records and claim history for complex, ambiguous or high-value claims. Clearly communicate the case details to insurers, Plum Operations, client/HR teams and hospitals and align all stakeholders towards a swift and well-reasoned decision.
• Provide Regular Status Updates: Proactively communicate the status of all cases taken up with relevant internal stakeholders and provide regular updates until resolution.
• Escalate Insurer Non-Responsiveness: Flag cases to the Claims Operations Lead where the insurer remains non-responsive beyond the agreed threshold, such as 3 working days, even after in-person follow-up.
• Build Insurer Relationships: Develop and maintain a strong, collaborative working relationship with the insurer's claims processing team to enable faster resolution of future stuck and escalated cases.
• Maintain Accurate Records: Maintain daily/weekly records of all stuck cases handled, including closures, ageing trends, status and blockers, and report these to the Claims Operations Lead.
• Identify Root Causes: Identify and tag the root causes of closed cases and share relevant learnings with the central Claims Operations team to reduce the number of cases requiring this level of escalation in the future.
• Deliver Performance Metrics: Maintain 100% weekly status reporting compliance and resolve more than 95% of escalations taken up without requiring HR, CHRO or legal involvement.