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
• Positive analytical and compr

📌 Senior Executive (Pune)
🏢 HDFC ERGO General Insurance
📍 Pune