Team Leader - Claim Investigation

About the Company
Niva Bupa Health Insurance Company Limited is a Public Listed Company on Stock exchange(s).
The company’s 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 Team Leader – Health Claims Investigation manages internal investigators and external agencies to maximize fraud detection and regulatory compliance. The role drives operational efficiency through daily case allocation, tracks team and vendor productivity, delivers continuous quality training, and resolves complex medical escalations.
Responsibilities
Workflow & Productivity Management
Identify red flags in health and personal accident claims, prescribing exact lines of inquiry for field teams.
Allocate claims daily to internal investigators and external agencies based on caseload expertise and geography.
Track daily productivity, active caseloads, and turnaround times (TAT) for internal teams and external vendors.
Monitor operational capacity daily to eliminate case backlogs and optimize ongoing investigation workflows.
Quality Assurance & Training
Track and evaluate daily investigation quality metrics for both in-house investigators and external vendors.
Design and deliver routine training programs covering fraud trends, medical coding, and investigative interview techniques.
Conduct regular quality audits on investigative reports and enforce corrective action plans for underperforming vendors.
Escalation & Operational Leadership
Review high-value, high-risk, or ambiguous claims to provide definitive direction on clinical fraud detection.
Standardize investigative protocols, evidence collection templates, and reporting formats across all investigation channels.
Stakeholder & Vendor Management
Monitor service level agreement (SLA) metrics and manage strategic relationships with external investigation agencies.
Liaise with healthcare providers, medical experts, legal counsel, and senior management regarding fraud trends.
Coordinate with internal teams to fast-track grievance resolution and eliminate operational bottlenecks during investigations.
Compliance & Documentation
Enforce standardized, legally defensible evidence evaluation protocols and provide direct guidance to field investigators.
Qualifications
Bachelor’s degree in Medicine, Nursing, Pharmacy, or Health Sciences (MBBS, BAMS, BHMS, BDS, B.Pharma, BPT, or B.Sc. Nursing)
Required Skills
Experience: 4+ years of experience in health insurance claims investigation or clinical fraud detection.
Leadership: 1–2 years of experience in a team leader, supervisory, or vendor management role.
Language Skills: Proficiency in Hindi, English and preference for fluency in the local regional language to effectively manage regional vendors, providers, and field investigations.
Technical Skills: Expert knowledge of medical terminologies, fraud patterns, and hospital billing practices.
Competencies: Data analysis, conflict resolution, technical report writing, and decisive problem-solving.

Work arrangement
No