AVP Health Info Analytics

A Leading Health Insurance Company is seeking an experienced AVP Health Info Analytics to lead its clinical claims analytics and medical risk management function in Mumbai. In this senior leadership position, you will direct end-to-end analytics on cashless and reimbursement claims, evaluate high-value medical dossiers, and assess medical necessity for hospitalization. Furthermore, you will build data models to detect abnormal claim patterns, minimize claims leakage, and optimize settlement quality. Consequently, this role is essential for driving clinical integrity and underwriting performance.

The AVP Health Info Analytics requires a qualified medical professional (MD, DNB, MBBS with MBA/MPH) who pairs deep clinical diagnostic understanding with advanced healthcare data analytics. Partnering closely with Fraud Control, Underwriting, Actuarial, and Network Hospital teams, you will lead a team of medical reviewers and build tracking dashboards using Power BI, SQL, or Python. Therefore, the organization is looking for a data-driven clinical leader who enforces IRDAI compliance guidelines seamlessly. If you want to steer healthcare analytics at scale, this position offers an exceptional platform.

Key Responsibilities

• Lead the analysis of end-to-end health insurance claims across cashless and reimbursement distribution channels.
• Review complex clinical records, diagnostic reports, treatment protocols, and hospital billings to assess medical necessity.
• Identify abnormal claim patterns, medical overutilization, unnecessary surgical procedures, and tariff cost escalation.
• Analyze healthcare datasets to identify hospitalization trends, disease prevalence, provider performance, and cost leakage.
• Collaborate with the Fraud Control Unit (FCU) to detect fraudulent, duplicate, or inflated healthcare provider claims.
• Design interactive analytical dashboards and executive MIS reports using SQL, Power BI, Tableau, or Python/R.
• Provide clinical guidance during claim escalations and collaborate with hospital networks and TPAs on complex cases.
• Lead, mentor, and build capability across a team of clinical reviewers, health data analysts, and medical adjudicators.

Requirements and Qualifications

• Educational qualification: MD, DNB, MBBS with MBA in Healthcare Management, MPH, or Health Informatics.
• 10-15+ Years of experience in Health Insurance, TPA, Healthcare Analytics, Medical Claims Adjudication, or Clinical Audit.
• Proven leadership background managing teams of medical reviewers and health data analysts in insurance.
• Advanced technical capabilities in healthcare analytics tools: SQL, advanced Excel, Power BI, Tableau, SAS, Python, or R.
• Comprehensive knowledge of health insurance claims lifecycles, healthcare coding standards, and IRDAI regulations.