Zonal Manager - Claim Investigation

About the Company

Niva Bupa Health Insurance Company Limited is a Public Listed Company on Stock exchange(s). The companys purpose is to give every Indian the confidence to access the best healthcare. It intends to play the role of an enabler in the lives of its customers and help them live life without constraints. This is reflected in its brand philosophy – Zindagi Ko Claim Kar Le. As of March 31, 2026, Niva Bupa had over 210 physical branches across India. It additionally offers health insurance through its ecosystem partners including 2.4 Lakh agents, close to 600 brokers, and over 120 Banca & Other Corporate Agency Partners. The company currently covers over 25 million lives and has over 10,500 hospitals empanelled in its hospital network. Niva Bupa has consistently maintained 90%+ claim settlement ratio over the last 5 financial years. With an employee base of over 10,100 people, the company is a certified Great Place to Work six times in a row.

About the Role

The Zonal Manager – Health Claims Investigation delivers strategic governance for the zonal fraud control framework. The role maintains strict vigilance on evolving fraud patterns, gathers market intelligence, oversees Team Leaders (TLs), in-house investigators, and external agencies, and onboard new vendor capabilities. Key focus areas include workflow innovation, strict SLA tracking, investigative quality, and absolute regulatory compliance.

Responsibilities

Fraud Vigilance & Market Intelligence

• Monitor health/accident claim trends to detect emerging fraud patterns early.
• Gather market intelligence on regional fraud syndicates, provider alliances, and systemic risks.
• Prescribe complex forensic lines of inquiry for high-stakes fraud cases escalated by team.
• Convert historical data and market insights into predictive indicators to stop claims leakage.

Agency Evaluation & Onboarding

• Source and evaluate new external investigation agencies based on expertise and footprint.
• Conduct reference checks and capability assessments during vendor onboarding.
• Define baseline operational expectations for newly empanelled agencies.
  
• Train external investigation agencies to align them with expected quality standards.

Performance & Workflow Innovation

• Monitor daily performance, productivity, and output quality for TLs, in-house teams, and vendors.
• Drive workflow innovation using digital tracking, automation tools, and streamlined case distribution.
• Oversee turnaround times (TAT) and zonal capacity planning to eliminate case backlogs.

Quality Assurance & SLA Management

• Enforce SLAs and performance metrics for both external agencies and in-house investigators.
• Audit internal and external teams regularly to ensure evidence is legally defensible.
• Review in-house investigators consistently to measure individual performance and SLA compliance.
• Renew, expand, or terminate vendor contracts based on performance audits and SLA adherence.

Regulatory Compliance & Alignment

• Ensure absolute zone-wide compliance with data privacy laws, IRDAI guidelines, and healthcare regulations.
• Resolution of field investigation issues and grievances.

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  Train internal teams and external vendors on emerging regulations and forensic compliance standards.

Qualifications

Bachelors degree in Medicine, Nursing, Pharmacy, or Health Sciences (MBBS, BAMS, BHMS, BDS, B.Pharma, BPT, or B.Sc. Nursing)

Required Skills

• Experience: 6+ years in health insurance claims investigation or clinical fraud management.
• Leadership: 3–4 years managing multi-tier teams (TLs, investigators) and external vendor networks.
• Language Skills: Fluent in Hindi and English; preference for primary regional languages within the zone.
• Technical Skills: Knowledge of fraud analytics, localized fraud patterns, and hospital billing practices.
• Competencies: Workflow innovation, data analysis, stakeholder management, and vendor onboarding acumen.

Preferred Skills

• Technical Skills: MS Office (Excel)
• Subject Matter Expertise: Industry Knowledge
• Process - Specific Skill: Field Investigation
• Communication
• Problem-solving