Manager Risk And Loss Mitigation Unit

• Physical field Investigation of claim assigned through system. • Handling physical verification, field visits to hospitals, pharmacies, diagnostic centers etc, collect evidence 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 used for 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