AVP - Health Claims Investigation - General Insurance Business

The details of the position are:

Company: Leading General Insurance Company Limited

Designation: AVP - Health claims investigation

Reporting to: VP - Health claims investigation

Location: Prabhadevi, Mumbai

Work Days: 5 Days

Job Description:

- Identify and build key investigation triggers, and adjudicate claims for final processing post digital/physical investigation.

- Identifying fraud claims based on digital, field investigation and analytical findings. Investigating PA claims to rule out genuineness of claims and lodging stringent/punitive measures against fraudulent claims, post discussion with legal team. Handing escalations of PA death claims in cooperation with the service escalation/legal team.

- Manage corporate as well as individual travel claims investigation. Identifying genuinity of claims to rule out fraud, manipulation in material facts, undisclosed critical illnesses in cashless, reimbursement and non-medical claims within specific timelines by field and digital mode of investigation.

- Interaction/discussion with the internal team, claims team and underwriting team regarding emerging frauds and new product information. Regular Industry collaboration in suspected multi-industry fraud claims.

- Identifying fraud/mispresented claims based on field/digital (video) investigation.

- Claim data analysis on emerging fraud, nexus, negative location, and blacklisted hospital claims at regular intervals.

- Interacting with the data analytics team to identify emerging fraud locations based on overall portfolio data at the company level.

- Focusing more on quality investigation with a digital approach for document collection and claim conclusion. Maintaining desired TAT in overall Benefit product.

- Handling escalations in Personal Accident death claims, regular coordination with the claim processing team for identification of any irregular trend.

- Case study presentation with internal stakeholders on emerging fraud claims/trend analysis on a monthly basis.

- UAT management for Product software upgradation at regular intervals.

- Conducting vendor training for soft skills management and for upgrading product knowledge on a monthly basis.

- For any further queries, write us at melissa@rightmatch.co.in.