Lead - Claim QC & Audit, Case Management Department: Claims Designation of the Manager: Head – Claims, FWA and Retail UW Location: Thane (Onsite) The role is responsible for ensuring accuracy, compliance, and quality in claims processing across both inhouse and TPA units. It involves concurrent and retrospective audits of cashless and reimbursement claims, covering indemnity and fixed benefit types. The position safeguards process integrity by identifying errors, mitigating risks, and driving corrective actions, while strengthening governance, compliance, and customer trust. • Claims Quality Check Quality check of processed claims Inhouse+ TPA (Concurrent/ Retrospective audit) Processing Unit - Inhouse and TPA Cashless and Reimbursement Benefit Type - Indemnity and fix benefit Review of FWA closure quality Sample investigation of send back claims. • High value Audit of Cashless & Reimbursement Claim 100% review of Claim with amount as below Indemnity claims above 5 Lakh Fix benefit above 20 Lakh Early claims within 1-2 team policy inception (New business/Port) Review of UW policy impact on claims Review of Product benefit on claim incidence rate Review of System related rules & validation Audit of NEFT/Payment process Assess compliance with the latest industry standards and regulations Audit of Clinical coding for accurate system adjudication and data analytics Boost documentation and reporting accuracy • Review of Tarrif & Identify abuse and renegotiation of tarrif Review of Provider tariff Review of Non package illness and help provider team for creation of packages. Review of existing packages, identify abuse and renegotiation