Medical Officer-Cashless Claims Investigations
Hyderabad, IN
6d ago

Desktop Investigation

  • Trigger identification through data at intimation / Referral stage
  • Social media searches
  • Cold calling using digital platforms
  • Identify key business people, link analysis
  • Claim Investigation

  • Allocation of assigned claims to respective vendors with case relevant triggers
  • Follow up for IR and TAT management
  • Level 1 QC clearance & validate the submissions against shared triggers
  • Success in claim investigation based upon strong medical & legal evidences
  • Preparing reports based on findings and observations and guide / Gathering and Analyzing the facts and developing & creating evidence which stands in court of law
  • Report submission and coordination with claims team.
  • Evidence Matrix Assurance

  • Ascertain evidence quality as per matrix
  • Validate each & every evidence with the case triggers
  • DMS of hardcopy maintenance
  • Escalation Management

  • Document Complaince through Field Investigation of HVC
  • Further Requirement Complaince
  • OFR and CFR with Stake holders
  • Data Management

  • MIS preparation and report reconciliation
  • Payment reconciliation with Vendors
  • Project tracking
  • Vendor Management

  • Vendor Empanelment & Training & Development
  • Ensure the ethics and compliance during managing the external investigators and self- investigation of cases
  • Vendor Payment Reconciliation
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