Purpose of the Role

The role is responsible for reviewing and decisioning Health & PA fraud claims, conducting Closed File Reviews (CFR) of concluded investigations, and proactively identifying fraud patterns and nexus across stakeholders to safeguard business integrity.

Key Responsibilities

1. Governance
- Review fraud cases referred by ILM and Claims teams, assess merits, and provide concurrence.
- KPI: TAT compliance.

2. Business Insights & Performance Monitoring
- Review ILM investigation reports and derive actionable insights to enhance operational effectiveness and quality.
- KPI: Process improvement.

3. Project Management
- Identify connections between claimants, intermediaries, vendors, hospitals, surveyors, and internal staff.
- Detect repeated fraud patterns involving common entities.




- KPI: Process efficiency.

4. Risk, Controls & Process Improvement
- Analyze fraud trends across claim categories and provide data-driven inputs for RMC and Legal.
- Support risk mitigation through structured reporting.
- KPI: Cost impact reduction.

Education & Experience Requirements
- Qualification: Bachelors Degree.
- Experience: Minimum 4+ years in claims management, investigations, or FMU operations.
- Preferred Knowledge: Health & PA claim investigation processes.

Interested candidates kindly share your resume at [email protected]

📌 Fraud Investigation Manager (Mumbai)
🏢 SBI General Insurance
📍 Mumbai