Claims Officer

Roles & Responsibilities -

Managing Health and PA Claims Investigation to prevent leakages, Train External Agencies, Analyze and identify Fraud, Data Analytics,

Liase with stakeholders for Assigned Geography

Review & Research evidence / documents submitted by Investigator to analyze overall fact & prepare report with recommendations

Gathering the missing points / data and finalizing the report.

Helping corporate team in getting require information from Investigators / Healthcare providers

TAT adherence

Case selection from the claim intimation data

Reviewing cases which are autoreferred basis output of system built Investigation KPI & Predictive Model

Prepare and coordinate field assignments to obtain relevant evidences & Information.

Follow-up & discussion with Investigators to close the case within defined TAT with desire outcome

Manage and prioritize case load effectively and efficiently to achieve positive results

Report submission basis facts provided by Investigator collected through other sources.

Raising Investigator payments through system

Conduct objective , fair , thorough, unbiased and timely investigations of triggered cases referred by claim team , auto referral by KPI & Predicitve Model, Manual selection through claim intimation dump

Improving success ratio and achieving target.

Coordiantion with Core team for cases discussion, escalation etc.

Appointment of External Investigating agency, training etc.

Tagging Fraud / caution Hospitals, De-empanelment of fraudulent providers , Creating & Updating database like negative customer database, negative treating doctor database , pathologist , chemist, lab tagging etc.

Keeping tab on industry alerts and enhancing database for better outcome .

Medical Graduate (MBBS/ BAMS/ BHMS/ BAMS)

Experience in Insurance Industry preferable in Health and PA Claims Investigations

Interested candidates kindly share resume at [email removed]