Roles & Responsibilities:

- Lead and supervise end-to-end medical claim investigations and audit activities.
- Coordinate effectively with internal investigation teams, claims teams, field investigators, hospitals, insurers, and TPAs.
- Monitor and control outstanding investigation cases to ensure closure within defined TAT.
- Conduct claims audit and identify discrepancies, fraud indicators, billing manipulation, document tampering, and suspicious claim patterns.
- Review investigation reports and ensure quality, accuracy, and completeness of findings.
- Analyze fraud trends and recommend preventive controls and process improvements.
- Prepare MIS dashboards, productivity reports, audit summaries, and management presentations using Excel and reporting tools.
- Ensure compliance with company policies, insurer guidelines, and regulatory requirements.
- Handle escalations from insurers, hospitals, and internal stakeholders professionally.
- Conduct team reviews, performance monitoring, mentoring, and training sessions for investigation staff.
- Coordinate with cross-functional teams for implementation of corrective and preventive actions.
- Support leadership in strategic initiatives related to fraud management and operational excellence.




- Maintain confidentiality and integrity while handling sensitive claim information.

Experience, Required Skills & Competencies:

- Experience Required: 10+ Years in Health Insurance / TPA / Claims Investigation.
- Strong knowledge of health insurance claims, medical terminology, hospitalization processes, and fraud investigation.
- Experience in claims audit, fraud control, field investigation coordination, and provider investigation.
- Excellent analytical and problem-solving skills.
- Advanced proficiency in Microsoft Excel (Pivot Tables, VLOOKUP/XLOOKUP, MIS reporting, data analysis).
- Positive communication, report writing, and stakeholder management skills.
- Ability to manage multiple priorities and handle high-pressure situations.
- Strong team coordination and leadership capabilities.
- Good understanding of hospital billing practices and claim adjudication processes.
- Knowledge of IRDAI regulations and health insurance operational processes will be preferred.

If anyone interested please share your updated Resume along with CCTC, ECTC & NP at [email protected]

📌 Sr Manager / AVP-Investigation / Fraud Control (Karnataka)
🏢 Medi Assist
📍 Karnataka