Deputy Manager - Risk And Loss Mitigation

Role & Designation: JM1 / JM2 (Health Claim Investigation) 

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.