Field Executive

Job SummaryThe Field Verification Officer is responsible for conducting on-the-ground investigations and audits of health insurance claims (primarily cashless and high-value reimbursement cases). The role involves making unannounced hospital visits to verify patient occupancy, auditing original hospital records on-site, interviewing patients regarding their medical history, and collecting physical or digital evidence to prevent insurance fraud and leakage.

• Key Responsibilities1. On-Site Hospital Audits & Patient Verification Surprise Occupancy Checks: Conduct unannounced visits to network and non-network hospitals to verify if the insured patient is physically admitted and receiving treatment in the assigned room/bed.
• Identity Verification: Cross-check the patient’s physical identity against government-issued IDs, policy documents, and hospital admission records to prevent personation fraud.
• Original Document Review: Access and inspect original hospital indoor case papers (ICP), nursing notes, temperature charts, and doctor order sheets directly from the ward or billing desk.
• 2. Field Investigation & Fact-FindingPatient & Attendant Interviews: Interview the patient or their relatives tactfully to verify the timeline of the illness, signs/symptoms, and past medical history (to check for non-disclosure of pre-existing diseases).
• Incident Verification: For accident-related claims (such as Road Traffic Accidents), visit the spot of the incident, local clinics, or neighborhood areas if necessary to corroborate the history of the trauma.
• Hospital Profile Verification: Assess the infrastructure of smaller nursing homes to ensure they meet the minimum criteria (e.g., number of operational beds, round-the-clock nursing staff, fully equipped OT) mandated by insurance guidelines.
• 3. Evidence Collection & Field ReportingDigital Evidence Gathering: Capture geo-tagged and time-stamped photographs or videos of the patient in the ward, original hospital registers, and relevant diagnostic films (with appropriate consent and privacy compliance).
• Daily Field Reporting: Submit detailed, objective field verification reports (FVR) immediately after the visit, detailing discrepancies, observations, and a clear recommendation (Genuine / Suspect / Fraudulent).
• Coordination with Back-Office: Work closely with back-office claim coordinators and medical auditors to share ground-level intelligence that helps clear pending or held claims quickly.
• Required Skills & QualificationsEducational Background:
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• Graduate in any discipline (Science, Commerce, or Arts).
• Highly Valued: Background in pharmacy, nursing, paramedical sciences, or past experience in law enforcement/security investigations.
• Core Competencies:
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• Investigative Mindset: Strong observational skills to spot anomalies, missing signatures, or altered dates in physical files.
• Communication & Negotiation: Ability to interact firmly yet politely with busy hospital administrators, medical superintendents, and anxious patients.
• Basic Medical & Insurance Knowledge: Understanding of common medical terms, standard hospital admission workflows, and basic insurance terms (like pre-existing conditions or cashless limits).
• Mobility & Local Geography: Must possess a valid driving license and a reliable two-wheeler, along with thorough knowledge of the assigned regional territory (e.g., specific city zones or districts).

Tech Savvy: Ability to use mobile reporting apps, upload digital evidence, and log daily visit statuses onto real-time field tracking spreadsheets or trackers.