We are looking for a medical professional with hands-on experience in health insurance claims investigation, medical claims assessment, fraud risk management, or provider audits. The role involves end-to-end investigation of health claims, medical review, fraud identification, field investigation coordination, and management of investigation vendors across India.

Key Responsibilities

- Conduct detailed review of cashless and reimbursement claims, medical records, treatment details, and hospital bills.
- Identify fraud indicators, discrepancies, policy violations, and potential abuse patterns.
- Handle investigations arising from fraud triggers, audits, analytics, business referrals, and whistleblower inputs.
- Coordinate telephonic, video, document-based, and field investigations as required.
- Manage and monitor PAN India investigation vendors, ensuring TAT, quality, and reporting standards.
- Review investigation reports and assess findings for claim decision-making.
- Coordinate with Claims, Medical, Fraud Control, Network, Legal teams, hospitals, doctors, and insured members.
- Prepare clear, evidence-based investigation reports with proper documentation and audit trails.
- Monitor vendor performance, productivity, quality, and effectiveness.




- Ensure adherence to internal investigation protocols and applicable regulatory requirements.
- Travel as required for investigations, audits, or stakeholder meetings.

Required Skills
- Strong knowledge of Health Insurance & TPA processes.
- Experience in Claims Investigation / Fraud Detection / Medical Claims Assessment.
- Ability to interpret medical records, treatment details, and hospital billing.
- Solid analytical, investigative, and decision-making skills.
- Good report writing and documentation skills.
- Experience in vendor management and TAT monitoring.
- Strong stakeholder management and communication skills.
- Ability to identify patterns, discrepancies, and potential fraud indicators.

Eligibility
- 3–8 years of relevant experience in Health Insurance Companies, TPAs, or Claims Investigation Agencies.
- Experience handling health insurance claims is mandatory.
- Medical qualification with relevant health insurance investigation experience preferred.
- Willingness to travel as required.
- Knowledge of multiple Indian languages will be an added advantage.

Benefits:
- Flexible schedule
- Provident Fund

Experience:
- Audit & Investigation: 3 years (Required)

Work Location: In person

📌 Claims Investigation & Audit (Mumbai)
🏢 Volo Health Insurance TPA
📍 Mumbai