Job Summary

The purpose of this role includes to do investigation of the cases referred to FWA team, perform the quality check of cases referred to investigation, and at an additional observation point allocate cases to vendors within a given Turnaround Time (TAT) and follow up with the vendor to cover 3-5 parameters along with supporting investigation documents to help in taking the final decision on the claim. FWA managers also monitor vendor quality of investigation, parameters covered during investigation, and evidences collected. Adherence to investigation TAT and concerns about vendor involvement with nexus producing wrong reports are to be observed. At branch level they also need to observe identified fraud activities by FLS, local hospitals, vendors, customers, sales managers, and provider managers, and report them to the zonal manager and vertical manager.

Location: Thane

Job Context / Major Challenges

- Once the claim verification request is received from the company, QC manager will study the claim, make additional triggers, refine triggers, to form customized questionnaire according to trigger, to allocate the claim for field investigation.
- 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.
- To verify/analyze evidence collected by field officers, to guide them if any rework is needed. Guide vendor to cover minimum 3 to 5 parameters (Insured, Hospital, Treating Doctor, Lab, Pharmacy) as per case requirement.
- Coordinate with vendor, to make closure report as per format, to close the FWA in the portal of ABHI,



and to update the FWA Manager / Central OPS team through mail about closure of the claim.
- To monitor claims from allocation to closure and to maintain quality of investigation, as per the given product TAT for investigation.
- To deliver assignments in TAT; manage vendors smartly so that work may not require weekends or public holidays.
- To maintain harmonious relationship with all managers in FWA, Claims, provider team, higher management staff in branch locations, clients, vendors, officer managers, and supporting staff.
- To maintain company targets: 95% TAT and 30% success ratio, with A-grade quality evidence and minimal escalations, to maintain hygiene in document collection.
- Confidentiality of work, nature of work, and insured data should be protected with utmost care.
- Digital work ethics include keeping camera on during meetings, ensuring timely joining, and minimizing background distractions during Teams/Digital/Virtual meetings or trainings.
- To execute all strategies and duties in an ethical way that increases business of the company.
- To perform activities to cut down the claim cost of the company.
- To identify, investigate and to report nexus/fraud claims/advisors, if any.
- To maintain data of all investigated cases and to identify fraud or new frauds in hospitals, pathologists, pharmacies,



or customers to improve overall performance.
- To maintain secrecy of internal or external data.
- No opinion/rejection/query discussions with the Zonal Manager/Claim Manager prior to closure.

Key Result Areas

- Investigation Portfolio Management - assigned geography
- Creative Investigation practices - fraud prevention measures
- Vendor Management
- Escalation litigation

Job Purpose of Direct Reports

Loss minimization by rejecting non-payable claims, and improving 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 on case-by-case basis; fortnightly basis; monthly basis; as required; for claim decisions where there is a difference of opinion; for policy termination; for de-empanelment/blacklisting of providers; for involvement of internal employee and sales employee; as and when post rejection when we receive escalation/grievance of the claim; as on case going to legal forum.
- External: NA

Organizational Relationships

- Head of FWA - Dr Pankaj Srivastava
- Zonal manager
- Zonal manager South East Central
- Manager AM/DM FWA
- Zonal manager North West
- SIGNOFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

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.

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