AM, FWA

Key Responsibilities

• Study claims upon receipt of verification requests from the company.
• Create and refine additional triggers and customize questionnaires based on triggers.
• Allocate claims for field investigation.
• Monitor the activity of field officers, provide guidance, and ensure investigations align with triggers and protocol.
• Obtain daily and timely updates and maintain them in the company's data.
• Verify and analyze evidence collected by field officers, guiding them on rework if necessary.
• Guide vendors to cover a minimum of 3 to 5 parameters (Insured, Hospital, treating Doctor, Lab & Pharmacy) per case requirement during field investigation.
• Coordinate with vendors to create closure reports as per format.
• Close FWA in the ABHI portal and update the FWA Manager / Central OPS team via email regarding claim closure.
• Monitor claims from allocation to closure, maintaining the quality of investigation according to product TAT.
• Deliver assignments within TAT and achieve company targets.
• Work as required, including evenings, holidays, and Sundays, as per senior requirements and company protocols, without compromising parameters.
• Maintain harmonious relationships with FWA managers, Claims, provider teams, higher management staff at the branch location, clients, vendors, officer managers, and supporting staff.
• Maintain company targets: 95% TAT and 30% Success ratio.
• Achieve A grade quality evidence with minimal escalations.
• Maintain hygiene in document collection.
• Protect the confidentiality of work, nature of work, and insured's database with utmost care.
• Adhere to digital work ethics, including keeping cameras on during meetings, providing prior information for late joining, and minimizing background distractions during virtual meetings and training.
• Execute strategies and efforts to ethically increase company business.
• Perform activities to reduce company claim costs.
• Identify, investigate, and report nexus/fraud claims/fraud advisors.
• Maintain data of all investigated cases to identify fraud/new fraud hospitals/fraud pathologists/fraud pharmacies/fraud customers, thereby improving overall performance.
• Maintain secrecy of internal or external data.
• Do not discuss opinion/pro-rejection/query cases with the Zonal Manager / Claim Manager prior to closure.