About the role
Investigation mangement ? Claim Investigation Allocation of assigned claims to respective vendors with case relevant triggers ? Follow up for IR and TAT management ? Level 1 QC clearance & validate the submissions against shared triggers ? Success in claim investigation based upon strong medical & legal evidences ? Preparing reports based on findings and observations and guide / Gathering and Analyzing the facts and ? Developing & creating evidence which stands in court of law ? Report submission and coordination with claims team. ? Evidence Matrix Assurance Ascertain evidence quality as per matrix Validate each & every evidence with the case triggers ? Escalation Management ? Payment reconciliation with Vendors Project tracking Vendor Management Vendor Empanelment & Training & Development ? Ensure the ethics and compliance during managing the external investigators and self- investigation of cases ? Vendor Payment Reconciliation ? Handling physical verification, field visits to hospitals, pharmacies, diagnostic centers etc, collect evidences and report for further action to Insurers, Corporates etc. ? Analyze data on utilization, outcomes and costs to determine trends and identify problem areas. ? Present findings to the management, which may include reviews, proposed solutions, and implementation of long- and short-term solutions for improvements in claim processing and cost savings. ? Desktop Investigation Trigger identification through data at intimation/Referral stage ? Social media searches ? Cold calling using digital platforms Identify key business people, link analysi