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