Zonal Manager - Claims Investigations

Role & responsibilities

Fraud Vigilance & Market Intelligence

• Monitor health/accident claim trends to detect emerging fraud patterns early.
• Gather market intelligence on regional fraud syndicates, provider alliances, and systemic risks.
• Prescribe complex forensic lines of inquiry for high-stakes fraud cases escalated by team.
• Convert historical data and market insights into predictive indicators to stop claims leakage.

Agency Evaluation & Onboarding

• Source and evaluate new external investigation agencies based on expertise and footprint.
• Conduct reference checks and capability assessments during vendor onboarding.
• Define baseline operational expectations for newly empanelled agencies.
• Train external investigation agencies to align them with expected quality standards.

Performance & Workflow Innovation

• Monitor daily performance, productivity, and output quality for TLs, in-house teams, and vendors.
• Drive workflow innovation using digital tracking, automation tools, and streamlined case distribution.
• Oversee turnaround times (TAT) and zonal capacity planning to eliminate case backlogs.

Quality Assurance & SLA Management

• Enforce SLAs and performance metrics for both external agencies and in-house investigators.
• Audit internal and external teams regularly to ensure evidence is legally defensible.
• Review in-house investigators consistently to measure individual performance and SLA compliance.
• Renew, expand, or terminate vendor contracts based on performance audits and SLA adherence.

Regulatory Compliance & Alignment

• Ensure absolute zone-wide compliance with data privacy laws, IRDAI guidelines, and healthcare regulations.
• Resolution of field investigation issues and grievances.
• Train internal teams and external vendors on emerging regulations and forensic compliance standards.

Preferred candidate profile

Experience:

• 6+ years in health insurance claims investigation or clinical fraud management.
• Leadership: 34 years managing multi-tier teams (TLs, investigators) and external vendor networks.
• Language Skills: Fluent in Hindi and English; preference for primary regional languages within the zone.
• Technical Skills: Knowledge of fraud analytics, localized fraud patterns, and hospital billing practices.
• Competencies: Workflow innovation, data analysis, stakeholder management, and vendor onboarding acumen.