We are looking for a medical qualified 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
Robust 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.
Solid 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.

Advantages:
Adaptable schedule
Provident Fund

Experience:
Audit & Investigation: 3 years (Required)

Work Location: In person

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