Fraud Vigilance & Market Intelligence
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.