Medi Claims Investigation Doctor

5 months ago

Vidyavihar Mumbai Maharashtra, India Tresbien HR Staffing Full time

Greetings from Tresbien HR

Hiring

Urgently required Doctors -Health Claims Investigator.

TPA Co
- Health Insurance.

Exp
- 3 Years +

Location
- Vidyavihar, Mumbai (1 Minute walking from station)

Qualification
- MBBS, BAMS, BHMS, BDS

Note
- "TPA Doctors only apply"

Job Profile
- Ø Responsibility of Pan India Investigation Operations & controlling & Fraud Detection.

Ø Review all Investigation related MIS before sending to Audit

Ø Review of Outstanding cases in Investigation & controlling of TAT

Ø Review of Fraud Cases & guide field team accordingly for Fraud Detection

Ø Guide & train QC doctors Team for preparing Reports

Ø Coordinate with Inter departmental Team members regarding escalation cases & resolve them accordingly.

Ø Handle & Resolve Investigation related Grievance cases & review & resolve accordingly.

Ø To oversee all IC’s Investigation % should be maintain.

Ø Handle all Audit recovery related Investigation cases & attend related meetings

Ø Self-conduct Field Investigation in Pan India in Fraud prone areas time to time basis for review & training purpose of field Investigators.

Ø Visit to all ICs for Investigation related issues & escalation

Ø Review & resolve escalation related to Rejected cases with Internal & external stakeholder by providing proper Adjudication in terms of investigation, Claims Audit.

Ø Conduct Hiring, Interviews & review of new Employees in Investigation department & conduct their Technical, Medical Training

Ø Conduct review of New Vendors & arrange end to end Empanelment along with Background verification

Ø Verify IT related issues, new software related developments & complete all development & conduct system UAT for same.

Ø Control Expenses of Field Investigators, review & approve on monthly basis.

Ø Conduct routinely audit of QC completed cases by QC Doctors & review & guide them accordingly.

Ø Coordinate with all Branch persons, Branch Heads & resolve their issues.

Ø Attend Investigation related Ombudsman cases, IRDA cases, Grievance cases, provide Legal, Technical, Medical support to Internal, External team members, Ics.

Ø Coordinate with Legal team for any legal cases & provide end to end replies, coordination.

Ø Review & control Leaves of In-House Pan Indian investigators Team if in access.

Ø Attend CRM team escalation & reply.

Ø Attend monthly, Quarterly review IC Meetings.

Ø Prepare Investigation & Fraud Detection Booklets along with Team members for IC Presentation.

Ø Review & conduct Investigation field Audit of Fraud prone areas, Locations from where no any Fraud Detection observed & try to Invent, arrange new techniques in Fraud Detection as per Market scenario.

Ø Conduct routinely Background verification of all Employees in Investigation Department, Vendors & take appropriate action accordingly with instruction of senior Management.

Ø To do Vendor payment with coordination of Senior Management approval, Vendor Quotation Negotiation.

Ø Daily review of Outstanding Data & allocation of cases.

Ø Review all IC reports before sending externally & guide team accordingly.

**Thanks & Regards**

**Sweta A**

**HR Recruitments**

**Tresbien HR Consultancy**

**Vileparle-Mumbai**

**Job Types**: Full-time, Permanent

**Salary**: Up to ₹1,200,000.00 per year

**Benefits**:

- Health insurance
- Provident Fund

Schedule:

- Day shift

Application Question(s):

- TPA experience Doctors only apply
- Do you have TPA Claims Audit & Field Investigation Experience -Yes\No
- How many years of TPA Claims Field Investigation Exp you have?

**Education**:

- Bachelor's (preferred)

**Experience**:

- Health Claims Investigation: 3 years (preferred)
- Investigation Claims: 3 years (preferred)
- Field Investigation: 3 years (preferred)

**Language**:

- English (preferred)

Willingness to travel:

- 50% (preferred)

Work Location: In person

**Speak with the employer**

+91 9833587015

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