COE-GMC investigation

Job Description

JOB PURPOSE Overseeing the process of GMC Investigations to Identify Fraud cases / Minimize liability of Company through extensive "in time" investigation and fact finding of all referred and triggered claims Ensure faster in time investigation of cases with minimum expenses to optimize claims cost saving/ recovery revenues. Developing risk management controls, contingency plans and Communicating recommendations to Under writer Developing Analytical Risk for prediction Managing and assisting team members and Responsible for Pan India PRINCIPAL ACCOUNTABILITIES Investigations & Quality Improvement Quality checks of the Investigations which is assigned through external and internal Vendors Review the evidence/documents collected to analyze the overall fact pattern of claim and provide recommendations Ensure LOB wise target achievement as per AOP Assisting on FIR filing on fraud identified cases Reviewing the forensic experts reports and giving relevant inputs to conclude the facts of the case. Conduct assessments to define and analyze possible risks and initiative projects as a tool of prevention In-depth Investigation of suspected fraud / triggered claims / Critical & High value claims. Responsible to Complete the Case within Stipulated Turn-around Time (TAT) Trigger Management Developing new trigger after analyzing the patterns of losses Recommend, implement and monitor preventative and corrective actions to ensure that quality assurance standards are achieved Evaluate Trigger efficiency and recommend the prioritization Monitor LR and Create new triggers based on the Outliers Risk & People Management Vendor Management – Training the external investigators, Control measures, Quality check for the investigation reports. Design processes to eliminate or mitigate potential risks: Fraud nexus, Location wise severity. Liaison closely with internal (claims, legal team or any team associated and external stakeholders (Lawyers, Police, Hospitals, Govt Missionaries, etc.) Manage and prioritize high case load effectively and efficiently to achieve results of Timeline and Success Training, evaluating, supporting the investigators, towards the fulfilment of the required actions Develop contingency plans to manage crises like Disaster claims, Pandemic situations etc. Enhance existing procedures in investigation by deploying new tools Prepare reports, presentations, recommendations and Performance review to Management Monthly Stat report and Sharing with Concern Channels of GMC Conducting meeting with GMC HR for identified fraud and taking actions Roles and Responsibilities 3