Cluster Manager-ILM- Health Investigations

Description

Desktop Investigation

• Trigger identification through data at intimation/Referral stage
• Social media searches
• Cold calling using digital platforms
• Identify key business people, link analysis

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
• DMS of hardcopy maintenance

Escalation Management

• Document Complaince through Field Investigation of HVC
• Further Requirement Complaince
• OFR and CFR with Stake holders

Data Management

• MIS preparation and report reconciliation
• 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

Skills Required

Industry & Competitive Awareness ; Claims Excellence ; Impactful Communication

Education/Qualification

Bachelor of Medicine ( Preferred - MBBS , BAMS, BHMS)

Desirable Skills

1.Good communication skills. 2.Flexible & adaptable to change. 3.Well versed with MS Office. 4.Should have good analytical and problem-solving skills. 5.Should be aware of the Local language.