Vice President Claims and Audit

Job Summary:

We are seeking a dynamic and experienced professional to lead health insurance claim management operations, with a specialized focus on risk mitigation, fraud investigation, and process efficiency. The Vice President Claim Management will oversee end-to-end claim processing, implement robust fraud detection frameworks, and ensure compliance with internal and external audit standards. A medical background (MBBS) is essential to effectively assess the clinical validity of claims and guide the medical audit team.

Key Responsibilities:

Provide strategic leadership for health insurance claims processing operations, ensuring efficiency, accuracy, and timely settlements.

Oversee risk management initiatives related to claim adjudication, fraud prevention, and abuse detection.

Develop and implement a fraud detection framework using a combination of medical insight, data analytics, and audit mechanisms.

Manage complex and high-value claims, ensuring alignment with policy terms and medical appropriateness.

Collaborate with internal stakeholders (underwriting, legal, medical officers, technology, etc.) to drive cross-functional improvements.

Lead, mentor, and grow a multidisciplinary team comprising claims assessors, medical reviewers, and fraud investigators.

Interface with auditors and regulatory bodies to ensure compliance and readiness for audits.

Analyze claims trends to identify potential risks, fraud patterns, and operational improvement opportunities.

Support system automation and digitization initiatives to streamline claims workflows and reduce processing time.

Required Qualifications & Skills:

MBBS degree is mandatory; additional qualifications in insurance, hospital administration, or risk management are a plus.

Minimum 1220 years of experience in health insurance claim management.

Deep understanding of health insurance claim lifecycle, policy terms, medical coding, and TPA management.

Strong grasp of audit processes, healthcare regulations, and fraud investigation techniques.

Proven ability to lead and manage high-performance teams.

Excellent analytical, decision-making, and communication skills.

Proficient in using health insurance platforms, data analytics tools, and reporting dashboards.

Preferred Experience:

Experience working with large insurance providers or TPAs.

Familiarity with Indian health insurance regulatory environment (IRDAI guidelines, etc.).