Cluster Manager- Health Investigations
2 weeks ago
Cluster Manager-ILM- Health Investigations
DescriptionDesktop Investigation
ᄋ Trigger identification through data at intimation/Referral stage
ᄋ Social media searches
ᄋ Cold calling using digital platforms
ᄋ Identify key business people, link analysis
Claim Investigation
ᄋ Allocation of assigned claims to respective vendors with case relevant triggers
ᄋ Follow up for IR and TAT management
ᄋ Level 1 QC clearance & validate the submissions against shared triggers
ᄋ Success in claim investigation based upon strong medical & legal evidences
ᄋ Preparing reports based on findings and observations and guide / Gathering and Analyzing the facts and developing & creating evidence which stands in court of law
ᄋ Report submission and coordination with claims team.
Evidence Matrix Assurance
ᄋ Ascertain evidence quality as per matrix
ᄋ Validate each & every evidence with the case triggers
ᄋ DMS of hardcopy maintenance
Escalation Management
ᄋ Document Complaince through Field Investigation of HVC
ᄋ Further Requirement Complaince
ᄋ OFR and CFR with Stake holders
Data Management
ᄋ MIS preparation and report reconciliation
ᄋ Payment reconciliation with Vendors
ᄋ Project tracking
Vendor Management
ᄋ Vendor Empanelment & Training & Development
ᄋ Ensure the ethics and compliance during managing the external investigators and self- investigation of cases
ᄋ Vendor Payment Reconciliation
Skills RequiredIndustry & Competitive Awareness ; Claims Excellence ; Impactful Communication
Education/QualificationGraduate/PG
Desirable Skills1.Good communication skills. 2.Flexible & adaptable to change. 3.Well versed with MS Office. 4.Should have good analytical and problem-solving skills. 5.Should be aware of the Local language.
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