Job Description

• Claim Investigation
• Report submission and coordination with claims team. Reviewing the Investigations report which is assigned through external and internal Vendors
• Prepare and coordinate field assignments to obtain relevant evidence and information.
• Field Investigation for the High value cases.
• Meeting with government agencies like, SHA, NHA, other Govt agencies in order to take the audit findings into logical conclusion.
• Evidence assessment, discussion with the Claims Team and action on fraud identified cases.
• Identification of Triggers conduct data analysis and explain plan of action for the field investigation.
• Responsible to complete the case within stipulated turn-around time (TAT).
• Conduct inquiries to ascertain the fact findings and to gather evidence in suspected fraud / triggered claims / Critical & High value claims.
• Visiting the hospitals alone or with Medical Team to conduct audit.
• Monitoring fraud trends, investigating emerging threats and quickly developing and deploying new strategies to manage those threats
• Providing innovative solutions for formation/strengthening of Fraud Risk tools for prevention, detection and monitoring of frauds.
• Work collaboratively with a diverse team of operational agents, fraud risk manager, data analysts/scientists, business insight analysts, subject matter experts
• Provide insight as Subject Matter Expert (SME) on Process and control fraud leakages
• Analyse fraud detection alerts and assess need for further investigation

• Quality Assurance
• Vendor Management \xe2\x80\x93 Training the external and internal investigators, Control measures, Quality check for the investigation reports.
• Preparing reports based on findings and observations and guide / train the investigators to fulfil the required actions as per the scheme guidelines.
• Training, evaluating, supporting the investigators, towards the fulfilment of the required actions
• Ensure the ethics and compliance during managing the external and internal investigators and self-investigation of cases.
• Document Compliance.

• Strategic Design \xe2\x80\x93 Execution and Deliverables
• Project scope assessment, identification of resources and implementation
• Periodic analysis of fraud trend and implementation of mitigant.
• Meeting with Government officials
• Manage and prioritize high case load effectively and efficiently to achieve results of Timeline and Success
• Review and research evidence/documents to analyze the overall fact pattern of claim and synthesize data into a professional report with recommendations

• MAJOR CHALLENGES

• Non contactability of beneficiaries. Non-Cooperation of Health Care Service Providers.
• Challenges in dealing with Government Authorities.
• As this is the public benefit scheme therefore involvement of local representative / Political figures.
• Managing and influencing external stakeholder interactions.
• Dependencies on the SNA with regards to disciplinary action.
• Availability of Medico Auditors (MBBS and Super Specialists) in the state.
• Identify and manage biases resulting from manual approach taken in conducting investigation of reported claims.
• Motivation of auditor despite frequent incident of man-handling and verbal abuse.