Job Position : Assistant Vice President – Fraud & Abuse Control

Job Description :

Job Purpose and Outline:

Company will be vulnerable to fraud from a number of sources whether individual, organised and opportunist. The perpetrators of this fraud may be customers, providers, intermediaries, Companies’ staff or associates / combinations of these. Investigations must be robust and accurate whilst recognising the political sensitivities and the impact these investigations may have on people. We need to ensure we control our claims spend and are not seen in the market place as an ‘easy touch.’ The job holder will manage a team of people which is responsible for managing fraud risk across the Companies’ business.

The job holder is needed to;

• Develop and implement a fraud policy for the business.
• Identify and investigate the constantly changing areas in which we are exposed to fraud.
• Initiate swift action to recover or avoid fraud costs.
• Ensure that long term fraud avoidance and preventative actions are in place.
• Support the Head of Healthcare Purchasing and Head of Medical Risk in all areas of diverse and complex investigations.
• Act as a subject matter expert to the rest of our business.
• Act as an ambassador to raise the profile of fraud across our business areas.

Accountabilities & Activities in detail :

Develop and implement a fraud policy for the Companies’ business.
Manage the Fraud and Investigations team, ensuring appropriate allocation of workload across the team.
Develop and implement system generated and manual fraud detection measures.
Responsible for accurate and timely interventions during the claiming process when cases have been flagged as potentially fraudulent.
Participate and contribute to Medical Risk team meetings to stay close to the latest developments and processes in claims management.
Achieve fraud avoidance or recovery targets as agreed by the Head of Healthcare Purchasing.
Ensure that correct operating procedures are followed and adhered to deliver water tight cases/outcomes to investigations.
Take personal accountability for developing fraud awareness and investigative skills attending meaningful and relevant conferences and training sessions.
Accountable for addressing sensitive issues with customers following accurate and thorough investigations. Agree course of action with Sales/Customer Service as appropriate, including cancellation of membership and recovery of monies where fraud is proven.
Where necessary, and in liaison with the Head of Healthcare Purchasing, institute provider counselling, de-panelling, and/or criminal prosecution.
In conjunction with the Head of Healthcare Purchasing and/or relevant Provider Contract team member, negotiate financial recoveries from providers/their professional association representatives/lawyers and complete with settlement agreement.
Fully support the Head of Healthcare Purchasing in the overall process of communicating any key messages to the business about fraud avoidance and updates/outcomes/case studies for training and development purposes.
Close liaison with the Medical Risk team and other members of the Healthcare Purchasing teams in terms of actions and outcomes.
To ensure that all team members are compliant with the regulations laid down by the IRDA.
Identify areas of improvement and effectively communicate these opportunities when they arise to the Head of Healthcare Purchasing.
Liaise closely with counterparts in other insurance businesses to share ideas, knowledge, policies, procedures, skills etc.
Liaise and share knowledge of fraudulent or suspected fraudulent providers and customers with counterparts at other health insurance companies and TPAs.
To support additional projects when requested by the Head of Healthcare Purchasing – including the implementation of new processes to reduce or identify fraud activity.
Liaison with customers/partners/providers/intermediaries/staff/regulators/TPAs/other insurers etc as required.
Other responsibilities as directed by the Head of Healthcare Purchasing.
Qualifications, Training & Experience:

• Demonstrated experience in the health insurance industry in fraud detection and prevention.
• Educated to degree level.
• Fluent in Hindi and English both written and spoken.
• IT literate.
• Good organisational, planning and delivery skills.
• Understanding of process management and improvement methodology.
• Strong negotiator.
• Ability to make considered business decisions based on explicit and implicit data and information. • Ability to work under pressure in a fast paced environment.
• Strong people/interaction skills.
• Diplomatic, self-confident and authoritative.
• Used to working in a high pressure environment and meeting challenging service standards.
• Knowledge of Indian law desirable but not essential

Competencies
• Analysing and investigation
• Thought and people leadership
• Customer and issues resolution focussed
• Business acumen and strong communication
• Formulating strategies and concepts
• Commercial thinking
• Negotiation
• Leading, mentoring and supervising
• Deciding and initiating action
• Relating and networking
• Persuading and influencing
• Creating and innovating
• Adhering to Companies’principles and values

Judgement Skills:

• Make day to day decisions on whether claims are paid or not
• Management of the fraud queues and work volumes

• Take ownership of escalated cases as and when necessary
• Prioritise tasks in a high pressure environment
• Ability to make decisions in a ‘project management’ environment
• Anticipate and take action on potential issues within own area
• Logical approach to prioritisation and time management
• Problem solving ability with the ability to consider out of the ordinary situations and know when it takes good business sense to override standard guidelines.
• Identification, facilitation of and consultation with stakeholders as appropriate when developing policies and processes and during investigations.
• Ability to provide honest, accurate and timely feedback regarding performance, giving guidance and encouragement to develop potential.

Key Relationships

Internal
• Head of Healthcare Purchasing
• Head of Medical Risk
• Medical Risk teams: Underwriting, Pre-Authorisation, Claims, Relationship Managers
• Customer Services
• Sales
• Legal Counsel
• Finance
• IT
• Marketing
• Any staff involved in or suspected of fraud, plus their line managers/senior managers as appropriate

External
• Companies’customers – individual and corporate
• Contracted and non-contracted providers
• Intermediaries
• Pre-policy health-check service partners
• Third Party Administrators
• Other health insurers
• IRDA
• Police / other authorities
• Industry groups
• Medical suppliers i.e. prostheses, medical devices and drugs
• Consultants eg. Clinical advisors, legal firms

Freedom of Action:
• Freedom to work on own initiative with little or no daily supervision..
• Expected to resolve majority of issues and problems with minimum upward referral.
• Within the dimensions of the Companies’business plan and strategy, and it’s principles and values.
• Treat all cases in the strictest confidence.

Dimensions:
Working across the customer service and operations team, to manage fraud risk in keeping with the values of the business. The business is a start up so the growth of the role may mean significant change in the next 3-5 years.

Company Name : Client of Symmetrical

Location : Delhi/NCR

Job Code : HR/SGS/102

Experience : 10

Job SalaryUpto - 30 Lacs (PA)

Last Date To Apply : 30-04-2014

Posted on : 12-03-2014