Key Responsibilities

Claim Investigation Management

- Review claim verification requests received from the company.
- Analyze claims, add/refine triggers, and prepare customized questionnaires.
- Allocate claims for field investigation.

Field Investigation Monitoring

- Guide and supervise field officers.
- Ensure investigations are conducted according to defined triggers and protocols.
- Take daily updates and maintain investigation records.

Evidence Verification & Analysis

- Review evidence collected by field officers.
- Provide guidance on rework where required.
- Ensure verification covers at least 3-5 parameters based on case requirements, including:
- Insured
- Hospital
- Treating Doctor
- Laboratory
- Pharmacy

Report Closure & Coordination

- Coordinate with vendors for closure reports.
- Prepare reports in the prescribed format.
- Close FWA cases on the ABHI portal.
- Update the FWA Manager/Central OPS team through email regarding claim closure

Quality & TAT Management

- Monitor claims from allocation to closure.
- Maintain investigation quality standards.
- Ensure investigations are completed within defined TATs.

Performance & Target Achievement

- Deliver assignments within timelines.
- Meet company productivity targets.
- Be available for work beyond regular hours,



including nights, holidays, and Sundays when required by business needs.

Stakeholder Management

Maintain effective relationships with:

- FWA team
- Claims team
- Provider team
- Senior management
- Clients
- Vendors
- Support staff

Operational Metrics

Maintain:

- 95% TAT achievement
- 30% success ratio
- A-grade quality evidence
- Minimize escalations.
- Ensure proper document hygiene and record maintenance.

Confidentiality & Digital Work Ethics

- Protect confidential company and insured data.
- Follow digital workplace protocols such as:
- Keeping camera on during meetings.
- Informing in advance about delays.
- Maintaining professionalism during virtual meetings and training sessions.

Fraud Detection & Business Protection

Execute activities that help reduce claim costs ethically.

Identify and report:

- Fraudulent claims
- Fraud networks/nexus
- Fraud advisors
- Maintain databases of suspicious hospitals, pharmacies, pathologists, and customers to strengthen fraud analytics.
- Maintain confidentiality of internal and external data.
- Avoid discussing rejection/query cases with Zonal Managers or Claim Managers before closure unless required.

📌 FWA Manager (Nagpur)
🏢 Career Shaper
📍 Nagpur