Fraud Investigation Manager

Purpose of the Role

The role is responsible for reviewing and decisioning Health & PA fraud claims, conducting Closed File Reviews (CFR) of concluded investigations, and proactively identifying fraud patterns and nexus across stakeholders to safeguard business integrity.

Key Responsibilities

1. Governance

• Review fraud cases referred by ILM and Claims teams, assess merits, and provide concurrence.
• KPI: TAT compliance.

2. Business Insights & Performance Monitoring

• Review ILM investigation reports and derive actionable insights to enhance operational effectiveness and quality.
• KPI: Process improvement.

3. Project Management

• Identify connections between claimants, intermediaries, vendors, hospitals, surveyors, and internal staff.
• Detect repeated fraud patterns involving common entities.
• KPI: Process efficiency.

4. Risk, Controls & Process Improvement

• Analyze fraud trends across claim categories and provide data-driven inputs for RMC and Legal.
• Support risk mitigation through structured reporting.
• KPI: Cost impact reduction.

Education & Experience Requirements

• Qualification: Bachelors Degree.
• Experience: Minimum 4+ years in claims management, investigations, or FMU operations.
• Preferred Knowledge: Health & PA claim investigation processes.

Interested candidates kindly share your resume at [email removed]