Claims Officer

SBI General Insurance; Mumbai; On-site; INR 900,000 - 1,300,000; Full time

Job summary

SBI General Insurance is seeking a dedicated professional for Health and PA claims investigations. The role involves assessing investigations, analyzing evidence, and coordinating with external agencies to prevent leakages and ensure timely resolutions.

Responsibilities include reporting findings, liaising with stakeholders, and maintaining robust data on fraud indicators to support the claims team and core functions.

Qualifications

• Medical graduate with background in health/PA claims investigations.
• Experience in insurance industry preferable for health and PA claims investigations.
• Ability to analyze documents and evidence from investigators.

Responsibilities

• Manage health and PA claims investigations to prevent leakages.
• Liaise with stakeholders across geography to support investigations.
• Review and research evidence submitted by investigators to prepare reports with recommendations.
• Coordinate field assignments to gather relevant evidences and information.
• Ensure timely investigations and adhere to defined TAT.
• Raising investigator payments through the system.
• Coordinate with core team for case discussions and escalation.
• Tag and update databases related to fraud and providers where applicable.

Skills

Data analytics

Fraud investigation

Stakeholder liaison

Investigations coordination

External agency training

Education

Medical Graduate (MBBS/ BAMS/ BHMS)

Job description

Roles & Responsibilities -

• Managing Health and PA Claims Investigation to prevent leakages, Train External Agencies, Analyze and identify Fraud, Data Analytics,
• Liase with stakeholders for Assigned Geography
• Review & Research evidence / documents submitted by Investigator to analyze overall fact & prepare report with recommendations
• Gathering the missing points / data and finalizing the report.
• Helping corporate team in getting require information from Investigators / Healthcare providers
• TAT adherence
• Case selection from the claim intimation data
• Reviewing cases which are autoreferred basis output of system built Investigation KPI & Predictive Model
• Prepare and coordinate field assignments to obtain relevant evidences & Information.
• Follow-up & discussion with Investigators to close the case within defined TAT with desire outcome
• Manage and prioritize case load effectively and efficiently to achieve positive results
• Report submission basis facts provided by Investigator collected through other sources.
• Raising Investigator payments through system
• Conduct objective , fair , thorough, unbiased and timely investigations of triggered cases referred by claim team , auto referral by KPI & Predicitve Model, Manual selection through claim intimation dump
• Improving success ratio and achieving target.
• Coordiantion with Core team for cases discussion, escalation etc.
• Appointment of External Investigating agency, training etc.
• Tagging Fraud / caution Hospitals, De-empanelment of fraudulent providers , Creating & Updating database like negative customer database, negative treating doctor database , pathologist , chemist, lab tagging etc.
• Keeping tab on industry alerts and enhancing database for better outcome .
• Medical Graduate (MBBS/ BAMS/ BHMS/ BAMS)
• Experience in Insurance Industry preferable in Health and PA Claims Investigations