Health Claims Investigation · Identification of suspected cases reported to the Company from the concerned location · Allocation of suspected cases to vendors for investigation with case relevant triggers · Self-investigation of suspected fraud cases · Follow up for Investigation Report with vendor ensuring closure of investigation within defined TAT · Level 1 QC clearance & validate the submissions against shared triggers · Preparing reports based on findings and observations duly supported by solid medical & legal evidences which stands in court of law · Identification of Hospitals/ individuals involved in malpractices and gathering market intelligence · Escalation Management & Grievance Management for the investigated cases · Maintaining proper MIS and report reconciliation · Vendor Payment Reconciliation,



Vendor Empanelment & Training & Development · Desktop Investigation Trigger identification through data at intimation/Referral stage · Data analysis with respect to the product loss ratio, Agent loss ratio, cases from suspected Hospitals and identify the adverse trend · 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. · Filing of police complaints and liaising with the police authorities for taking necessary action against fraudulent individuals / hospital and others

📌 Manager - Risk and Loss Mitigation (Ahmedabad)
🏢 HDFC ERGO General Insurance
📍 Ahmedabad