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.

2) Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.

Business Workforce Number
(Max 254 Characters)

On Roll – 6000+

Offroll/ Part time – 4000+

Unit Workforce Number
(Max 254 Characters)

On Roll – 6000

Offroll/ Part time – 4000+

Function Workforce Number
(Max 254 Characters)

On Roll – 800

Offroll/ Part time - 279

Department Workforce Number
(Max 254 Characters)

On roll – 29

Off roll - 2

Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

3) Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters)

1) 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.

2) 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.

3) 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 during field investigation.

4) 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.

5) To monitor claims from allocation to closure and to maintain quality of investigation. As per given product TAT for investigation.

6) To deliver assignment in TAT, we need to manage vendor smartly so that we need not to work on weekends and public holidays.

7) To maintain harmonious relationship with all managers in FWA, Claim, provider team, higher management staff in branch location, / clients/ Vendors/officer managers/supporting staff.

8) To maintain target of company, 95% TAT and 30% Success ratio, A grade quality evidence with minimal escalations, to maintain hygiene in document collection.

9) 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/pro rejection/query cases discussion with Zonal Manager /Claim manager prior closure.

4) Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)- Maximum 10 KRAs can be updated

Key Result Areas (Max 1325 Characters)

Supporting Actions (Max 1325 Characters)

1.Investigation Portfolio Management - assigned Geography

2.Innovative Investigation practices & Fraud prevention measures

3. Vendor Management

4. Escalation & litigation

1.a) Portfolio Monitoring & Management.
1.b)Investigation performance w.r.t success rate & TAT 1.c)Look after quality of triggers , referrals & quality of investigation for better outcome.

1. d) Portfolio Impact in retail & group

2.a) Number of seeding activities carried out & Outcome
2.b) Number of fraud hospitals identified and DE panelled from the network
2.c) Insured / Advisor / Hospital Blacklisting
2.d) No. of policies recommended for cancellation
2.e) No. of policies tagged for renewal block
2.f) dummy cases to be investigated against investigator and report to be submitted
2.g) Project for suspected fraud location

2.h) no hospital infrastructure audit/month which resulted in to DEempanelment/blacklist/recovery etc.

3.a) Vendor development 3. b) Vendor Training

3.c) vendor performance monitoring

4.a) Escalation to next level
4.b) Cases present in Ombudsmen / litigation

5) Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

Loss minimization by rejecting non payable claims, improve customer satisfaction by quick settlement of payable cases.

6) 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 (Max 80 Characters)

Frequency

Nature (Max 1325 Characters)

Internal

Claim Team

Underwriting team

Provider team

Market conduct team

Grievance team

Legal team

Daily Baisis

Case to case basis

Fortnightly basis

Monthly basis

As & when required

For claim decision where difference of opinion

For policy termination

For de empanelment /blacklisting of providers

For involvement of internal employee and sales employee

As &on when post rejection when we receive escalation /grievance of the claim

As & on when case gone in legal forum

External

7) Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)

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Job Description:

Basic Details: Fill the required information about business, unit, location, position, reports to position and date of updation of JD

1) Job Purpose: Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters)