Executive Officer, Claims

Claims Assessment & Settlement

• Review, assess and process insurance claims in accordance with policy provisions, company guidelines and regulatory requirements.
• Verify claim eligibility, coverage and supporting documentation to ensure accurate claim settlement.
• Prepare claim assessments and settlement recommendations within prescribed turnaround times.
• Escalate complex, disputed, or high-value claims to appropriate authorities.
• Investigation & Fraud Management
• Conduct or support field investigations, including site visits, evidence collection, claimant interviews and verification of claim circumstances.
• Prepare investigation reports and document findings.
• Identify and escalate suspicious, fraudulent, or high-risk claims through investigation findings and AI-based fraud indicators.
• Coordinate with investigators, healthcare providers and relevant external stakeholders as required.
• Digital, Technology & AI Enablement
• Utilize Claims Management Systems (CMS), digital platforms and workflow automation tools for efficient claim processing.
• Leverage AI-enabled tools to support claim assessment, fraud detection and decision-making.
• Support digital claims submission, e-KYC verification, electronic documentation and paperless operations.
• Identify opportunities to improve claims processes through technology, automation, and data-driven insights.
• Data Analytics, Reporting & Compliance
• Analyze claims data and trends to support operational efficiency and risk management.
• Prepare claims, investigation and management reports.
• Maintain accurate claim records and documentation for audit and regulatory purposes.
• Ensure compliance with company policies, regulatory requirements and anti-fraud standards.
• Customer & Stakeholder Management
• Deliver excellent customer service by providing timely communication and resolution of claim-related inquiries.
• Coordinate with hospitals, surveyors, investigators, service providers and other stakeholders to facilitate claim processing and verification.
• Maintain professional relationships with internal and external stakeholders to ensure effective claim resolution.
• Contribute to a customer-centric claims experience while meeting service-level commitments.