Website:
firstquadrants.com
Job details:
We are looking for an experienced professional to lead a national Health Claims Investigation function for a general insurance organisation.
Role: Lead - Health Claims Investigation
Location: Mumbai, India (Pan-India travel as required)
Function: Claims - Health Claims Investigation & Fraud, Waste and Abuse (FWA) Management
Reporting To: Head of Claims
About the Role
The role will be responsible for strengthening investigation quality, fraud detection, governance and operational effectiveness across Health, Personal Accident, Disability and Travel claims.
The position combines claims investigation leadership, medical/clinical expertise, fraud management, analytics and technology-led investigation to build a scalable and effective national investigation framework.
Key Responsibilities
- Lead a pan-India team of Health Claims Investigation Field Managers, ensuring quality, productivity and timely investigations.
- Develop investigation strategies, SOPs, governance and quality standards across Health, PA, Disability and Travel claims.
- Strengthen fraud detection frameworks covering provider fraud, fabricated claims, billing manipulation and other emerging fraud risks.
- Lead the development of a Fraud Engine using rule-based, predictive and AI-driven triggers.
- Partner with Data Science, Technology and Analytics teams on AI/ML, fraud scoring, anomaly detection and automation.
- Drive improvements in fraud savings, claims leakage, TAT and operational efficiency.
- Review complex and high-value claims requiring strong medical judgement.
- Work closely with Claims, Underwriting, Legal, Compliance, IT, Analytics, TPAs and investigation partners.
- Present investigation performance, fraud trends and savings to senior management.
Ideal Candidate Profile
- 10–15+ years of experience in Health Claims Investigation.
- Proven experience managing a national/geographically distributed investigation team.
- Strong exposure to Health, Personal Accident, Disability and Travel claims.
- Strong medical/clinical knowledge; MBBS or equivalent preferred.
- Experience in fraud detection, fraud engines, analytics and technology-led investigation.
- Proven track record in fraud savings and claims leakage reduction.
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