COE-GMC investigation

Job Description

JOB PURPOSE (Summarize in one statement why your job exists; and how it contributes to the overall mission/objective of the organization.) 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 ORGANISATIONAL CHART (Please complete the organization chart below using only the generic and descriptive job titles.) Comments Xxx PRINCIPAL ACCOUNTABILITIES (List the accountabilities associated with the job.) 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 MAJOR CHALLENGES (Describe the major challenges you face on an on-going basis in carrying out your job.) Managing and influencing external stakeholder interactions As Internal dependencies which are not in direct control are high settling Claims within the TAT becomes challenging Identify and manage biases resulting from manual approach taken in conducting investigation of reported cases Manage high risk of life for team involved in investigation due to increase in number of assaults during investigation. Attract and manage talent efficiently as manpower required needs to have high IQ and orientation for investigation DECISIONS (Mention the key decisions taken by job holder at his end and the decisions for which the job holder goes to superior with options and recommendations or seek approval). Quality check of the investigation report submitted Court cases and giving deposition Decisions to pay on certain claims referred for investigation Develop risk management controls and systems INTERACTIONS (The key working relationships or routine contacts a job holder needs to have INSIDE and OUTSIDE the organization to accomplish the job.) Internal Clients Roles you need to interact with inside the organization to enable success in your day to day work Claims Team [HAT] Legal Team Business Team Under writer -HAT Actuarial External Clients Roles you need to interact with outside the organization to enable success in your day to day work Investigation agents Forensic experts Police Authorities District Administration Data Vendors Automation Partners DIMENSIONS (List the significant numerical data which will reflect the scope and scale of activities concerning this job). Financial Dimensions (These should be quantifiable numerical amounts like annual budgets, project costs, annual revenue, purchase value etc.). Financial impact of INR 100 Cr crore via prevention, mitigation and process enhancement Other Dimensions (Indication of some of the significant volumes associated with the job like number in team/ staff handled etc). Success of cases referred for Investigation Maintaining the Turn Around Time Enhancing the success of cases investigated Vendor Management: Training, Timely payment for the services Total Team Size – 10 Direct Reports – 10 Show more Show less