Zonal Manager - Claims Investigations

Niva Bupa; Mumbai; On-site; INR 1,800,000 - 3,000,000; Full time

Job summary

Niva Bupa is seeking an experienced Fraud Vigilance & Market Intelligence leader in Mumbai to drive proactive fraud detection, market intelligence, and QA of investigations. You will lead multi-tier teams, coordinate with external agencies, and implement workflow innovations to reduce claim leakage.

The role requires strong analytics, regulatory awareness, and the ability to onboard and train partner agencies across zones. Fluency in Hindi and English is preferred.

Qualifications

• 6+ years in health insurance claims investigation or clinical fraud management.
• Leadership: 3+ years managing multi-tier teams and vendor networks.
• Fluent in Hindi and English; regional language proficiency preferred.
• Knowledge of fraud analytics and hospital billing practices.
• Excellent stakeholder management and onboarding acumen.

Responsibilities

• Monitor health/accident claim trends to detect emerging fraud patterns early.
• Gather market intelligence on regional fraud syndicates, provider alliances, and systemic risks.
• Prescribe complex forensic lines of inquiry for high-stakes fraud cases escalated by team.
• Convert historical data and market insights into predictive indicators to stop claims leakage.
• Source and evaluate new external investigation agencies based on expertise and footprint.
• Conduct reference checks and capability assessments during vendor onboarding.
• Train external investigation agencies to align them with expected quality standards.
• Monitor daily performance, productivity, and output quality for TLs, in-house teams, and vendors.
• Drive workflow innovation using digital tracking, automation tools, and streamlined case distribution.
• Oversee turnaround times (TAT) and zonal capacity planning to eliminate case backlogs.
• Enforce SLAs and performance metrics for both external agencies and in-house investigators.
• Audit internal and external teams regularly to ensure evidence is legally defensible.
• Review in-house investigators consistently to measure performance and SLA adherence.

Skills

Fraud analytics

Data analysis

Stakeholder management

Vendor onboarding

Leadership

Hindi

English

Job description

Role & responsibilities

Fraud Vigilance & Market Intelligence

• Monitor health/accident claim trends to detect emerging fraud patterns early.
• Gather market intelligence on regional fraud syndicates, provider alliances, and systemic risks.
• Prescribe complex forensic lines of inquiry for high-stakes fraud cases escalated by team.
• Convert historical data and market insights into predictive indicators to stop claims leakage.

Agency Evaluation & Onboarding

• Source and evaluate new external investigation agencies based on expertise and footprint.
• Conduct reference checks and capability assessments during vendor onboarding.
• Define baseline operational expectations for newly empanelled agencies.
• Train external investigation agencies to align them with expected quality standards.

Performance & Workflow Innovation

• Monitor daily performance, productivity, and output quality for TLs, in-house teams, and vendors.
• Drive workflow innovation using digital tracking, automation tools, and streamlined case distribution.
• Oversee turnaround times (TAT) and zonal capacity planning to eliminate case backlogs.

Quality Assurance & SLA Management

• Enforce SLAs and performance metrics for both external agencies and in-house investigators.
• Audit internal and external teams regularly to ensure evidence is legally defensible.
• Review in-house investigators consistently to measure individual performance and SLA compliance.
• Renew, expand, or terminate vendor contracts based on performance audits and SLA adherence.

Regulatory Compliance & Alignment

• Ensure absolute zone-wide compliance with data privacy laws, IRDAI guidelines, and healthcare regulations.
• Resolution of field investigation issues and grievances.
• Train internal teams and external vendors on emerging regulations and forensic compliance standards.

Preferred candidate profile

Experience:

• 6+ years in health insurance claims investigation or clinical fraud management.
• Leadership: 34 years managing multi-tier teams (TLs, investigators) and external vendor networks.
• Language Skills: Fluent in Hindi and English; preference for primary regional languages within the zone.
• Technical Skills: Knowledge of fraud analytics, localized fraud patterns, and hospital billing practices.
• Competencies: Workflow innovation, data analysis, stakeholder management, and vendor onboarding acumen.