AM-FWA(Bangalore)

Job Purpose The purpose of this role includes 1. To do investigation of the cases referred to FWA team, do the quality check of cases referred to investigation and at additional observation point for investigation allocate case to vendor in a given TAT and take follow up with vendor to cover 3 5 parameter along with supporting investigation documents which will help in taking final decision on claim. Payable/rejection, query). FWA manager need to also monitor closely to vendor on quality of investigation, parameters covered during investigation, evidences collected during investigation. Adherence to investigation TAT, vendor involvement with nexus are giving wrong report. In branch level they also need to observe FLS, local hospitals, vendors, customers, sales manager, provider manager involved in any fraudulent activity and same need to be reported to zonal manager and vertical manager. Job Context & Major Challenges Once the claim verification request is received from company, QC manager will study the claim, make additional triggers, refines triggers, to form customize questionnaire according to trigger, to allocate the claim for field investigation. To monitor activity of field officers, to guide them and to get the claim investigated according to trigger and as per protocol, to take daily and timely updates, to maintain updates in our data. To verify/ analyses evidence collected by field officers, to guide them if any rework is needed. Guide vendor to cover minimum 3 to 5 parameter (Insured, Hospital, treating Doctor, Lab & Pharmacy) as per case requirement Coordinate with vendor, to make closure report as per format, to close the FWA in portal of ABHI, to update FWA Manager / Central OPS team through mail about closure of claim. To monitor claims from allocation to closure and to maintain quality of investigation. As per given product TAT for investigation. To deliver assignment in TAT, we need to manage vendor smartly so that we need not to work on weekends and public holidays. To maintain harmonious relationship with all managers in FWA, Claim, provider team, higher management staff in branch location, / clients/ Vendors/officer managers/supporting staff. To maintain target of company, 95% TAT and 30% Success ratio, A grade quality evidence with minimal escalations, to maintain hygiene in document collection. Confidentiality of work, Nature of work and insured s data base should be protected with utmost care. Digital work ethics like keeping camera on while attending meeting, prior information about late joining, distraction at background while Microsoft Teams/ Digital/Virtual meet/ training Challenges: To execute all strategies, duties, efforts which increases business of company in ethical way. a. To perform all those activities to cut down the claim cost of the company. b. To identify, investigate and to report nexus/ fraud claims/ fraud advisor etc if any c. To maintain data of all investigated cases, to identify fraud/ new fraud hospitals/ fraud pathologist/ fraud pharmacy/ fraud customers which will improves overall performance. d. To maintain secrecy of our internal or external data. e. No opinion/rejection/query cases discussion with Zonal Manager /Claim manager prior closure. Key Result Areas Investigation Portfolio Management assigned Geography Innovative Investigation practices & Fraud prevention measures Vendor Management Escalation & litigation Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 23 lines for each report) Loss minimization by rejecting non payable claims, improve customer satisfaction by quick settlement of payable cases. Relationships Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives Relationship Type: Internal Frequency: Daily Basis Nature: Case to case basis Contacts: Claim Team, Underwriting team, Provider team, Market conduct team, Grievance team Relationship Type: Exter .