Cluster Manager-Reimbursement Claims Investigations

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Job Description

Desktop Investigation
Identify triggers at intimation/referral stage using data analytics.
Conduct social media searches and cold calling via digital platforms.
Perform link analysis to identify key business connections.
Claim Investigation
Allocate claims to vendors based on case-specific triggers.
Monitor Investigation Reports (IR) and manage Turnaround Time (TAT).
Perform Level 1 QC and validate submissions against triggers.
Ensure success in claim investigations through strong medical and legal evidence.
Prepare detailed reports and coordinate with the claims team.
Evidence Matrix Assurance
Validate evidence quality as per defined matrix.
Maintain documentation and hardcopy records in DMS.
Escalation & Compliance
Handle escalations through field investigations for high-value claims.
Ensure compliance with OFR (Outstanding Field Requirements) and CFR (Case Finalization Requirements).
Data & MIS Management
Prepare MIS reports and reconcile data.
Track projects and reconcile vendor payments.
Vendor Management
Empanel, train, and develop vendors.
Ensure ethical practices and compliance during investigations.
Manage vendor payment reconciliation.