AM- FWA (Thane - GCorp)

Aditya Birla Health Insurance Company Limited; Delhi; Remote; INR 1,200,000 - 1,600,000; Full time

Job summary

Aditya Birla Health Insurance Company Limited seeks a FWA Manager to oversee claim verification and field investigations. You will study claims, create triggers, allocate cases for fieldwork, and guide officers to collect evidence according to protocol.

Responsibilities include monitoring investigator activity, coordinating with vendors, and delivering timely closure reports while maintaining data confidentiality and adhering to company procedures.

Qualifications

• Experience in claim verification processes.
• Ability to guide field officers and manage field investigations.
• Coordinate with vendors to ensure timely closure reports.

Responsibilities

• Study each claim and customize questionnaire according to trigger.
• Monitor field officers' activity and guide them in investigations.
• Ensure closure reports are prepared per format and communicated to stakeholders.
• Maintain confidentiality and data hygiene.

Skills

Claim verification

Field investigation

Vendor coordination

Quality monitoring

Data confidentiality

Team coordination

Job description

JD for FWA Manager

• 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.
• 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.
• 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, to achieve companies target and, to work in such a way which will not hamper parameter, working from home (at night, on holidays, Sundays) must be done as per requirement of seniors and as per company protocol.
• 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 10) To execute all strategies, duties, efforts which increases business of company in ethical way.

• To perform all those activities to cut down the claim cost of the company.
• To identify, investigate and to report nexus/ fraud claims/ fraud advisor etc if any
• To maintain data of all investigated cases, to identify fraud/ new fraud hospitals/ fraud pathologist/ fraud pharmacy/ fraud customers which will improves overall performance.
• To maintain secrecy of our internal or external data.
• No opinion/pro rejection/query cases discussion with Zonal Manager /Claim manager prior closure.