TMFWA Professional

Aditya Birla Insulators; Bengaluru; On-site; INR 500,000 - 800,000; Full time

Job summary

Aditya Birla Insulators is seeking a dedicated FWA Investigator to handle investigations referred to the FWA team, perform quality checks, and allocate cases to vendors within the defined TAT, followed by vendor follow-up to gather necessary evidences for final claim decisions.

The role requires close monitoring of vendor performance, adherence to TAT, and reporting of any fraudulent activity to zonal and vertical managers, while maintaining confidentiality and data hygiene across cases.

Responsibilities

• Investigate cases referred to the FWA team and perform quality checks.
• Allocate cases to vendors within the defined TAT and follow up for supporting documents.
• Monitor vendor performance and ensure evidences collected to support final claim decisions.

Job description

Job Summary

The purpose of this role includes 1. To do investigation of the cases referred to FWA team, do the quality check of cases referred to investigation and at additional observation point for investigation allocate case to vendor in a given TAT and take follow up with vendor to cover 3 5 parameter along with supporting investigation documents which will help in taking final decision on claim. Payable/rejection, query). FWA manager need to also monitor closely to vendor on quality of investigation, parameters covered during investigation, evidences collected during investigation. Adherence to investigation TAT, vendor involvement with nexus are giving wrong report. In branch level they also need to observe FLS, local hospitals, vendors, customers, sales manager, provider manager involved in any fraudulent activity and same need to be reported to zonal manager and vertical manager.

Location Thane

Responsibilities

• To do investigation of the cases referred to FWA team, do the quality check of cases referred to investigation and at additional observation point for investigation allocate case to vendor in a given TAT and take follow up with vendor to cover 3 5 parameter along with supporting investigation documents which will help in taking final decision on claim. Payable/rejection, query.
• Adherence to investigation TAT, vendor involvement with nexus are giving wrong report. In branch level they also need to observe FLS, local hospitals, vendors, customers, sales manager, provider manager involved in any fraudulent activity and same need to be reported to zonal manager and vertical manager.
• 2) Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.

Job Context Major Challenges

• 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.
• To deliver assignment in TAT, we need to manage vendor smartly so that we need not to work on weekends and public holidays.
• 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 Challenges To execute all strategies, duties, efforts which increases business of company in ethical way.
• a. To perform all those activities to cut down the claim cost of the company.
• b. To identify, investigate and to report nexus/ fraud claims/ fraud advisor etc if any
• c. To maintain data of all investigated cases, to identify fraud/ new fraud hospitals/ fraud pathologist/ fraud pharmacy/ fraud customers which will improves overall performance.
• d. To maintain secrecy of our internal or external data.
• e. No opinion/pro rejection/query cases discussion with Zonal Manager /Claim manager prior closure.

Key Result Areas

• Investigation Portfolio Management assigned Geography
• Innovative Investigation practices Fraud prevention measures
• Portfolio Monitoring Management
• Vendor Management
• Escalation to next level
• Vendor Development
• Vendor Training
• Vendor Performance Monitoring
• Ombudsmen / litigation
• Insured / Advisor / Hospital Blacklisting
• Number of policies cancelled
• Number of policies tagged for renewal block
• Project for suspected fraud location
• No hospital infrastructure audit/month which resulted in DEempanelment / blacklist / recovery

Relationships

• Internal relationships: Claim Team, Underwriting team, Provider team, Market conduct team, Grievance team, Legal team
• Frequency/Nature: Daily basis; Fortnightly basis; Monthly basis; As and when required; For claim decision where difference of opinion; For policy termination; For de empanelment / blacklisting of providers; For involvement of internal employee and sales employee; As on when post rejection when we receive escalation / grievance of the claim; As on when case goes to legal forum