- Monitor health/accident claim trends to detect emerging fraud patterns early.
- Gather market intelligence on regional fraud syndicates, provider alliances, and systemic risks.
- Prescribe complex forensic lines of inquiry for high-stakes fraud cases escalated by team.
- Convert historical data and market insights into predictive indicators to stop claims leakage.
Agency Evaluation & Onboarding
- Source and evaluate recent external investigation agencies based on expertise and footprint.
- Conduct reference checks and capability assessments during vendor onboarding.
- Define baseline operational expectations for newly empanelled agencies.
- Train external investigation agencies to align them with expected quality standards.
Performance & Workflow Innovation
- Monitor daily performance, productivity, and output quality for TLs, in-house teams, and vendors.
- Drive workflow innovation using digital tracking, automation tools, and streamlined case distribution.
- Oversee turnaround times (TAT) and zonal capacity planning to eliminate case backlogs.
Quality Assurance & SLA Management
- Enforce SLAs and performance metrics for both external agencies and in-house investigators.
- Audit internal and external teams regularly to ensure evidence is legally defensible.
- Review in-house investigators consistently to measure individual performance and SLA compliance.
- Renew, expand, or terminate vendor contracts based on performance audits and SLA adherence.
Regulatory Compliance & Alignment
- Ensure absolute zone-wide compliance with data privacy laws, IRDAI guidelines, and healthcare regulations.
- Resolution of field investigation issues and grievances.
- Train internal teams and external vendors on emerging regulations and forensic compliance standards.
Preferred candidate profile
Experience:
- 6+ years in health insurance claims investigation or clinical fraud management.
- Leadership: 34 years managing multi-tier teams (TLs, investigators) and external vendor networks.
- Language Skills: Fluent in Hindi and English; preference for primary regional languages within the zone.
- Technical Skills: Knowledge of fraud analytics, localized fraud patterns, and hospital billing practices.
- Competencies: Workflow innovation, data analysis, stakeholder management, and vendor onboarding acumen.