As a TPA Department Head focused on investigations, you'll lead a team to conduct thorough inquiries into claims, ensuring accuracy and compliance, while also identifying potential fraud and ensuring smooth claim processing. Conduct objective, fair, thorough, unbiased and timely investigations into allegations of fraud, waste or abuse committed by claimants / providers / any other stakeholders in health insurance claims. Review and research evidence/documents to analyse the overall fact pattern of claim and synthesize data into a professional report with recommendations. Prepare and coordinate field assignments to obtain relevant evidence and information. Coordinate with Corporate office to provide recovery strategies and use legal resources for assistance. Manage and prioritize a large and varied case load effectively and efficiently to achieve positive result. Write Narrative report based on investigation conducted with evidence to support. Key Responsibilities: Lead and Manage Investigation Team: Supervise, train, and mentor investigation staff, ensuring they have the necessary skills and resources to perform their duties effectively. Investigate Claims: Conduct in-depth investigations into health insurance claims, gathering evidence, interviewing witnesses, and analysing data to determine the validity of claims. Fraud Detection and Prevention: Identify potentially fraudulent activities, develop and implement fraud prevention strategies, and report suspicious activity to relevant authorities. Compliance and Regulatory Adherence: Ensure all investigation activities comply with relevant regulations, industry standards, and company policies. Data Analysis and Reporting: Analyse claim data to identify trends, patterns, and areas for improvement, and prepare reports for management and stakeholders. Reporting and Communication: Preparing comprehensive investigation reports, summarizing findings, and making recommendations. Presenting findings and recommendations to management or relevant stakeholders. Collaborating with other teams and external parties as needed. Other Potential Responsibilities: Drafting Suspicious Activity Reports (SARs). Participating in proactive investigative projects. Assisting with drafting and serving subpoenas. Providing information for making arrests. Maintaining expertise in relevant laws, regulations, and industry standards. Staying up-to-date on emerging trends and technologies in the field of investigation. Process Improvement: Continuously evaluate and improve investigation processes to enhance efficiency, accuracy, and effectiveness. Collaboration: Work collaboratively with other departments, such as claims processing and underwriting, to ensure seamless operations and accurate claim adjudication. Decision Making: Make sound decisions regarding claim investigations, considering all relevant factors and evidence. Technical Skills: Proficient in using relevant software and tools for data analysis, investigation, and reporting. Medical Knowledge: Possess a strong understanding of medical terminology, procedures, and healthcare systems. Qualifications: Bachelor's degree in a related field (e.g., Healthcare Administration, Business Administration, or Law). Experience in health insurance claims investigation or a related field. Strong analytical and problem-solving skills. Excellent communication and interpersonal skills. Ability to work independently and as part of a team. Knowledge of relevant regulations and industry standards.
