The purpose of this role includes 1.To do investigation of the cases referred to FWA team, do the quality check of cases referred to investigation and at additional observation point for investigation allocate case to vendor in a given TAT and take follow up with vendor to cover 3 5 parameter along with supporting investigation documents which will help in taking final decision on claim. Payable/rejection, query). FWA manager need to also monitor closely to vendor on quality of investigation, parameters covered during investigation, evidences collected during investigation.

Adherence to investigation TAT, vendor involvement with nexus are giving wrong report. In branch level they also need to observe FLS, local hospitals, vendors, customers, sales manager, provider manager involved in any fraudulent activity and same need to be reported to zonal manager and vertical manager.

Job Context

Major Challenges

Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business / Unit / Function / Department / Section.

- 1. Once the claim verification request is received from company, QC manager will study the claim, make additional triggers, refines triggers, to form customize questionnaire according to trigger, to allocate the claim for field investigation.

- 1. To monitor activity of field officers, to guide them and to get the claim investigated according to trigger and as per protocol, to take daily and timely updates, to maintain updates in our data.

- 1. To verify/ analyses evidence collected by field officers, to guide them if any rework is needed. Guide vendor to cover minimum 3 to 5 parameter (Insured, Hospital, treating Doctor, Lab Pharmacy) as per case requirement

- 1. Coordinate with vendor,



to make closure report as per format, to close the FWA in portal of ABHI, to update FWA Manager / Central OPS team through mail about closure of claim.

- 1. To monitor claims from allocation to closure and to maintain quality of investigation. As per given product TAT for investigation.

- 1. To deliver assignment in TAT, we need to manage vendor smartly so that we need not to work on weekends and public holidays.

- 1. To maintain harmonious relationship with all managers in FWA, Claim, provider team, higher management staff in branch location, / clients/ Vendors/officer managers/supporting staff.

- 1. To maintain target of company, 95% TAT and 30% Success ratio, A grade quality evidence with minimal escalations, to maintain hygiene in document collection.

- 1. Confidentiality of work, Nature of work and insured s data base should be protected with utmost care. Digital work ethics like keeping camera on while attending meeting, prior information about late joining, distraction at background while Microsoft Teams/ Digital/Virtual meet/ training. Challenges To execute all strategies, duties, efforts which increases business of company in ethical way. a. To perform all those activities to cut down the claim cost of the company. b. To identify, investigate and to report nexus/ fraud claims/ fraud advisor etc if any c. To maintain data of all investigated cases,



to identify fraud/ recent fraud hospitals/ fraud pathologist/ fraud pharmacy/ fraud customers which will improves overall performance. d. To maintain secrecy of our internal or external data. e. No opinion/pro rejection/query cases discussion with Zonal Manager /Claim manager prior closure.

Key Result Areas

- 1.a) Portfolio Monitoring Management.
- 1.b) Investigation performance w.r.t success rate TAT
- 1.c) Look after quality of triggers , referrals quality of investigation for better outcome.
- 1.d) Portfolio Impact in retail group
- 2.a) Number of seeding activities carried out
- 2.b) Number of fraud hospitals identified and DE panelled from the network
- 3.a) Vendor development
- 3.b) Vendor Training
- 3.c) vendor performance monitoring
- 4.a) Escalation to next level
- 4.b) Cases present in Ombudsmen / litigation Job Purpose of Direct Reports

Loss minimization by rejecting non payable claims, improve customer satisfaction by quick settlement of payable cases.

Relationships

- Internal: Claim Team

• Underwriting team

• Provider team

• Market conduct team

• Grievance team

• Legal team.

Frequency: Daily Basis.

Nature: Case to case basis.

- Internal: For claim decision where difference of opinion.

Frequency: As when required.

Nature: For policy termination.

- Internal: For de empanelment / blacklisting of providers.

Frequency: As when required.

Nature: For involvement of internal employee and sales employee.

- External: NA

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 TMFWA Professional (Hyderabad)
🏢 Aditya Birla Insulators
📍 Hyderabad