Position Overview We are seeking a diligent, detail-oriented, and proactive Field Investigator to join our Health Insurance Claims department. The primary role of the investigator is to verify the authenticity and validity of health insurance claims by conducting on-site investigations at hospitals, clinics, and claimant residences. This position is critical in preventing fraudulent claims and ensuring the integrity of our claims processing system. The ideal candidate will be self-motivated, possess excellent observational skills, and be comfortable with extensive local travel. Key ResponsibilitiesConduct thorough field investigations for health insurance claims as assigned by the claims team. Travel to various locations, including hospitals, nursing homes, and policyholders' residences, to gather facts and verify information. Verify the details of hospitalization, treatment provided, and medical history of the claimant. Interview claimants, family members, hospital staff, and attending doctors to corroborate claim information. Collect and examine relevant documents, such as hospital records, medical bills, discharge summaries, and diagnostic reports. Take photographs and record statements as necessary to build a comprehensive case file. Identify discrepancies, inconsistencies, or potential red flags indicative of fraudulent activity. Prepare and submit detailed, objective, and timely investigation reports using our company's mobile application and online portal. Maintain strict confidentiality and handle sensitive personal and medical information with the utmost integrity. Coordinate effectively with the in-house claims processing team to provide clear and actionable findings. Mobility: Must be willing to travel extensively within the assigned territory on a daily basis. Personal Attributes: Excellent observational and analytical skills. Strong communication and interpersonal skills to interact with diverse individuals. High level of integrity, ethics, and professionalism. Ability to work independently with minimal supervision. Good time management and organizational skills to handle multiple cases simultaneously. Preferable Qualifications Possession of a valid two-wheeler driving license. ( Optional) Ownership of a reliable bike or scooter for efficient travel. Prior experience in investigation, claims processing, or a similar field role is highly advantageous. Familiarity with basic medical terminology and hospital procedures. Good knowledge of the local geography and language(s) of the assigned area. What We Offer Competitive salary and performance-based incentives. Reimbursement for travel (fuel) and mobile expenses. Comprehensive personal accident insurance coverage. Opportunities for training and professional development. A dynamic and supportive work environment
Medical Officer – Medical Audit & Fraud 1. Job Summary We are seeking a meticulous and analytical medical professional (BAMS/BHMS/BUMS) to join our Fraud Control and Claims Investigation team. This is a non-clinical, role crucial for analysing the Health Insurance Claim documents. The Medical Officer will act as the key clinical expert, responsible for applying medical knowledge to detect, investigate, and report on suspected cases of health insurance fraud, waste, and abuse (FWA). You will be the primary link between our data analytics team, on-ground investigators, and the claims processing unit, using your expertise to scrutinise medical records, validate the medical necessity of treatments, and identify aberrant billing patterns from network and non-network providers. 2. Key Responsibilities Clinical Claims Review: Conduct in-depth medical reviews of high-value and suspicious claims flagged by the system, TPAs (Third-Party Administrators), or analytics team. Scrutinise admission notes, treatment protocols, diagnostic reports, and discharge summaries to validate the diagnosis and medical necessity of services rendered. Assess the appropriateness of the length of stay (ALOS) and the justification for high-cost consumables, medicines, or implants. Fraud Detection & Analysis: Apply clinical knowledge to identify red flags and patterns of potential fraud. This includes, but is not limited to: Unbundling: Billing for services separately that are typically part of a package (e.g., GIPSA PPN packages). Upcoding: Inflating the severity of an illness or billing for a more complex procedure than was performed. Lack of Medical Necessity: Performing investigations or procedures not clinically justified by the patient's diagnosis. Provider Collusion: Identifying patterns suggesting collusion between providers and policyholders (e.g., fabricated bills, planned "paper" admissions). Investigation & Reporting: Collaborate with data analysts to interpret billing data and provide clinical context to aberrant trends. Work closely with on-ground SIU investigators to guide hospital visits and medical record verification. Prepare detailed, clear, and objective medico-legal reports and case summaries of investigative findings, forming the basis for claim denial, provider warnings, or legal action. Stakeholder & Provider Liaising: Act as the medical point-of-contact for complex queries from the claims and legal teams. Communicate with medical teams at TPAs to ensure alignment on fraud detection policies. Engage directly with hospital medical teams and doctors to challenge discrepancies, question treatment protocols, and seek clarification on billing. Compliance & Policy: Stay updated on IRDAI (Insurance Regulatory and Development Authority of India) anti-fraud guidelines and other relevant regulations. Assist in developing and refining internal medical audit protocols and fraud trigger rules. 3. Qualifications & Experience Essential: Degree: Any recognised medical degree from a recognized institution. Registration: Must possess a valid and unrestricted registration with the respective councils Clinical Experience: Minimum of 2-3 years of hands-on clinical experience (e.g., as a Resident Medical Officer, in general practice, or a specific specialty) to provide a strong foundation in clinical decision-making. Highly Preferred: Industry Experience: 2+ years of experience in a similar role within a Health Insurance Company or a Third-Party Administrator (TPA). 4. Required Skills & Competencies Investigative Mindset: A natural curiosity and a "forensic" approach to detail. You must enjoy "connecting the dots" and digging deep into records. Strong Analytical Skills: Ability to analyse complex medical information alongside financial (billing) data to spot inconsistencies. Knowledge of Indian Healthcare Ecosystem: Strong familiarity with Indian hospital billing practices, common treatment tariffs, and surgery packages (e.g., PPN rates). Understanding of standard medical protocols and treatment costs across different types of hospitals (e.g., multispecialty chains vs. local nursing homes). Assertiveness & Integrity: High ethical standards and the confidence to challenge senior medical professionals and hospital authorities firmly but professionally. Excellent Communication: Ability to write clear, concise, and defensible reports for non-medical stakeholders (legal, management). Tech Savvy: Proficient in MS Office, especially MS Excel, for analysing data and preparing reports. Experience with claims management software is a plus.