Senior Associate

Physical field Investigation of claim assigned through 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 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