Cluster Manager - Health Insurance Claims Investigation

Cluster Manager- Health

Description

1. Desktop Investigation

• Identify triggers at intimation/referral stage using data analytics.
• Conduct social media searches and cold calling via digital platforms.
• Perform link analysis to identify key business connections.

2. Claim Investigation

• Allocate claims to vendors based on case-specific triggers.
• Monitor Investigation Reports (IR) and manage Turnaround Time (TAT).
• Perform Level 1 QC and validate submissions against triggers.
• Ensure success in claim investigations through strong medical and legal evidence.
• Prepare detailed reports and coordinate with the claims team.

3. Evidence Matrix Assurance

• Validate evidence quality as per defined matrix.
• Maintain documentation and hardcopy records in DMS.

4. Escalation & Compliance

• Handle escalations through field investigations for high-value claims.
• Ensure compliance with OFR (Outstanding Field Requirements) and CFR (Case Finalization Requirements).

5. Data & MIS Management

• Prepare MIS reports and reconcile data.
• Track projects and reconcile vendor payments.

6. Vendor Management

• Empanel, train, and develop vendors.
• Ensure ethical practices and compliance during investigations.
• Manage vendor payment reconciliation.

Skills Required

Industry & Competitive Awareness Claims Excellence Impactful Communication

Education/Qualification

Graduation/PG

Desirable Skills

None