Circle Head - ILM Health

Description

Desktop Investigation

ﾷ Trigger identification through data at intimation/Referral stage

ﾷ Social media searches

ﾷ Cold calling using digital platforms

ﾷ Identify key business people, link analysis

Claim Investigation

ﾷ Allocation of assigned claims to respective vendors with case relevant triggers

ﾷ Follow up for IR and TAT management

ﾷ Level 1 QC clearance & validate the submissions against shared triggers

ﾷ Success in claim investigation based upon strong medical & legal evidences

ﾷ Preparing reports based on findings and observations and guide / Gathering and Analyzing the facts and developing & creating evidence which stands in court of law

ﾷ Report submission and coordination with claims team.

Evidence Matrix Assurance

ﾷ Ascertain evidence quality as per matrix

ﾷ Validate each & every evidence with the case triggers

ﾷ DMS of hardcopy maintenance

Escalation Management

ﾷ Document Complaince through Field Investigation of HVC

ﾷ Further Requirement Complaince

ﾷ OFR and CFR with Stake holders

Data Management

ﾷ MIS preparation and report reconciliation

ﾷ Payment reconciliation with Vendors

ﾷ Project tracking

Vendor Management 

ﾷ Vendor Empanelment & Training & Development

ﾷ Ensure the ethics and compliance during managing the external investigators and self- investigation of cases

ﾷ 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.