Head Of Department - Investigation

Job Discerption:

1. Leadership

Develop, implement, and monitor the investigation strategy aligned with organizational objectives. Establish policies, protocols, and SOPs for investigation and fraud detection.

Coordinate with insurers, providers, and internal teams to streamline investigation processes.

2. Operational Management

Supervise and guide investigation officers, field investigators, and analysts.

Ensure timely allocation, completion, and closure of investigation cases.

Maintain robust documentation and MIS for all investigation activities.

3. Fraud Detection & Control

Identify patterns, trends, and high-risk areas in claims processing. Lead initiatives for early detection of fraud and abuse. Develop risk-scoring models for suspicious claims.

4. Regulatory & Insurer Compliance

Ensure adherence to IRDAI regulations and insurer guidelines. Ensure confidentiality and ethical handling of sensitive information. Prepare reports for regulatory audits and insurer reviews.

5.Stakeholder Management

Work closely with insurance companies, hospitals, and law enforcement agencies. Act as the escalation point for disputed investigations. Represent the organization in fraud committees, audits, and industry forums.

6. Team Development

Build and train a high-performing investigation team. Conduct regular workshops on fraud awareness and investigation techniques. Monitor team productivity and skill enhancement.

7. An engagement External Investigation Agency-

An engagement and constant review of the External Investigation agencies. New Empanelment of Agencies to ensure Geographic spread, Fraud pockets. Negotiation of the Rates of the agencies on the basis of Business volume. Market review on authentication of the agencies and Rebalancing agency portfolio. Conduct regular workshops on fraud awareness and investigation techniques.

Monitor team productivity and skill enhancement.

Visits- Visit to branches whenever require for the sensitization /training/ performance review of Team. Visit to Insurer/ Hospital /Broker for any investigation related work/ presentations.

Key Result Areas (KRAs):

1. Fraud Detection & Prevention Reduction in fraudulent payouts and leakage on month-on-month review, find out the possible avenues and plugs the losses.
2. Turnaround Time (TAT) Timely completion of investigation reports.
3. Quality of Reports Accuracy, depth, and comprehensiveness of investigation findings.
4. Regulatory Compliance Insurer wise, audit was compliance with the reports
5. Cost Efficiency Optimizing investigation cost per case without compromising quality.
6. Responsiveness to Stake holders Positive feedback from insurers and internal teams.
7. Team Performance Productivity, training, and retention of investigation staff.
8. Alerts to Networking Department on the basis of Fraud detection from Network and Non-Network hospitals.

Key Performance Area-

1. Fraud Control & Savings % reduction in fraudulent payouts year-on-year. Total financial savings achieved through investigations (absolute value & % of claims investigated).
2. Operational Efficiency Average TAT for completion of investigations (benchmark e.g., 710 days). % of investigations closed within defined SLA. Ratio of cases investigated to cases recommended for further action.
3. Quality & Accuracy % of insurer/management-approved investigation reports without major discrepancies. Error rate in submitted reports (target: less than 2%).
4. Compliance & Governance Number of non-compliance observations in audits (target: Zero).