TMFWA Professional

Aditya Birla Insulators; Thane; On-site; INR 900,000 - 1,300,000; Full time

Job summary

Aditya Birla Insulators seeks a dedicated FWA Investigator Manager to lead investigations of claims, perform quality checks, and coordinate with vendors, branch teams, and Central OPS to ensure timely closure of cases within prescribed TAT.

The role emphasizes monitoring vendor performance, guiding field officers, ensuring robust evidence collection, maintaining data confidentiality, and achieving high standards of accuracy and control in line with organizational goals.

Responsibilities

• Investigate cases referred to the FWA team and perform quality checks.
• Allocate cases to vendors within the defined TAT and follow up to cover required parameters with supporting documents.
• Monitor vendor performance on investigation quality, evidence collection and adherence to protocols.
• Coordinate with vendors, branch managers, and the Central OPS team to close claims in the ABHI portal.

Job description

Job Summary

The purpose of this role includes

1. 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).
2. FWA manager need to also monitor closely to vendor on quality of investigation, parameters covered during investigation, evidences collected during investigation.
3. Adherence to investigation TAT, vendor involvement with nexus are giving wrong report.
4. 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.

Dimensions

1. Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.
2. Business Workforce Number Unit Workforce Number On Roll 6000 Offroll/ Part time 4000+
3. Function Workforce Number On Roll 800 Offroll/ Part time 279
4. Department Workforce Number On roll 29 Off roll 2
5. Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

Job Context Major Challenges

1) 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.

3) 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

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.

5) 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, we need to manage vendor smartly so that we need not to work on weekends and public holidays.

7) To maintain harmonious relationship with all managers in FWA, Claim, provider team, higher management staff in branch location, / clients/ Vendors/officer managers/supporting staff.

8) To maintain target of company, 95% TAT and 30% Success ratio, A grade quality evidence with minimal escalations, to maintain hygiene in document collection.

9) 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.

• 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.

Key Result Areas

• Investigation Portfolio Management assigned Geography
  • Portfolio Monitoring Management.
  • Investigation performance w. r. t success rate TAT
  • Look after quality of triggers , referrals quality of investigation for better outcome.
  • Portfolio Impact in retail group
• Number of seeding activities carried out
• Number of fraud hospitals identified and DE panelled from the network
• Vendor Management
• Escalation litigation
• Insured / Advisor / Hospital Blacklisting
• No. of policies recommended for cancellation
• No. of policies tagged for renewal block
• dummy cases to be investigated against investigator and report to be submitted
• Project for suspected fraud location
• no hospital infrastructure audit/month which resulted in to DEempanelment / blacklist / recovery etc.
• Vendor development
• Vendor Training
• vendor performance monitoring
• Escalation to next level
• Cases present in Ombudsmen / litigation

Direct Reports

Loss minimization by rejecting non payable claims, improve customer satisfaction by quick settlement of payable cases.

Relationships

• Internal: Claim Team
• Internal: Underwriting team
• Internal: Provider team
• Internal: Market conduct team
• Internal: Grievance team
• Internal: Legal team
• External: NA

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.