Fraud Investigation Manager

Job description

Purpose of the Role The role is responsible for reviewing and decisioning Health & PA fraud claims, conducting Closed File Reviews (CFR) of concluded investigations, and proactively identifying fraud patterns and nexus across stakeholders to safeguard business integrity. Key Responsibilities 1. Governance • Review fraud cases referred by ILM and Claims teams, assess merits, and provide concurrence. • KPI: TAT compliance. 2. Business Insights & Performance Monitoring • Review ILM investigation reports and derive actionable insights to enhance operational effectiveness and quality. • KPI: Process improvement. 3. Project Management • Identify connections between claimants, intermediaries, vendors, hospitals, surveyors, and internal staff. • Detect repeated fraud patterns involving common entities. • KPI: Process efficiency. 4. Risk, Controls & Process Improvement • Analyze fraud trends across claim categories and provide data-driven inputs for RMC and Legal. • Support risk mitigation through structured reporting. • KPI: Cost impact reduction. Education & Experience Requirements • Qualification: Bachelors Degree. • Experience: Minimum 4+ years in claims management, investigations, or FMU operations. • Preferred Knowledge: Health & PA claim investigation processes. Interested candidates kindly share your resume at rashmika.manjrekar@sbigeneral.in