Director of Claims, Risk & Fraud

Job Summary :

We are seeking a dynamic and experienced professional to lead health insurance claim management operations, with a specialized focus on risk mitigation, fraud investigation, and process efficiency. The Vice President – Claim Management will oversee end-to-end claim processing, implement robust fraud detection frameworks, and ensure compliance with internal and external audit standards. A medical background (MBBS) is essential to effectively assess the clinical validity of claims and guide the medical audit team.

Key Responsibilities :

• Provide strategic leadership for health insurance claims processing operations, ensuring efficiency, accuracy, and timely settlements.
• Oversee risk management initiatives related to claim adjudication, fraud prevention, and abuse detection.
• Develop and implement a fraud detection framework using a combination of medical insight, data analytics, and audit mechanisms.
• Manage complex and high-value claims, ensuring alignment with policy terms and medical appropriateness.
• Collaborate with internal stakeholders (underwriting, legal, medical officers, technology, etc.) to drive cross-functional improvements.
• Lead, mentor, and grow a multidisciplinary team comprising claims assessors, medical reviewers, and fraud investigators.
• Interface with auditors and regulatory bodies to ensure compliance and readiness for audits.
• Analyze claims trends to identify potential risks, fraud patterns, and operational improvement opportunities.
• Support system automation and digitization initiatives to streamline claims workflows and reduce processing time.

Required Qualifications & Skills :

additional qualifications in insurance, hospital administration, or risk management are a plus.

Preferred Experience :