Deputy Manager - Risk And Loss Mitigation

Job Description

· Physical field Investigation of claim assignedthrough system.

· Handling physical verification, field visits to hospitals, pharmacies, diagnostic centers etc, collect evidences and report for further action to Insurers, Corporates etc.

· Preparing reports based on findings and observations and guide / Gathering and Analyzing the facts and developing & creating evidence which stands in court of law

· Report submission in CIMA (In house system that is being usedfor Investigation)

· Maintain healthy and cordial relationship with hospitals and TPA desk.

· Ascertain evidence quality as per matrix Validate each & every evidence with the case triggers

· MIS preparation and report reconciliation

· Ensure the ethics and compliance while investigating a claim

· Analyze data on utilization, outcomes to determine trends and identify problem areas.

· Present findings to the management, which may include reviews, proposed solutions, and implementation of long- and short-term solutions for improvements in claim processing and cost savings.

· Identification of Hospitals/ individuals involved in malpractices to create database

· Escalation &Grievance Management for the investigated cases

· Filing of police complaints and liaising with the police authorities for taking necessary action against fraudulent individuals / hospital and others

Required Qualifications:

· Medical Graduates such as BAMS/BHMS/BPT or BDS with working experience of Health insurance industry preferably with Claims investigation/ processing experience

· Experience Range: Minimum 3 – 6 years

· Excel and computer

• Medical degree: BHMS / BAMS / BDS / BPT

Preferred Work experience

• First reference to Insurance Industry experience

• Practical experience of clinical management in hospitals

• Claims processing experience

• Knowledge on investigations & its procedures.

• Medical record familiarity

• Good analytical and comprehension skills.