Medi Claims Investigation Doctor

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