Senior Manager - Fraud Control Operations

Overview

The role focuses on supporting the Senior Manager in overseeing fraud control operations within Operations and Accounts divisions. The aim is to ensure prompt issue resolution aligned with regulatory standards, organizational policies, and compliance norms. Additionally, it involves recognizing and evaluating compliance risks related to operational activities to help enhance and consolidate the company's operational processes and functions.

Challenges

• Escalation of fraudulent incidents, especially related to counterfeit claims due to elevated repudiations.
• Challenges with data accuracy in internal systems during investigations.
• Absence of a unified platform consolidating all investigation information, requiring access to disparate systems.
• Difficulty obtaining timely and quality responses from agents, channel partners, and various departments during case probes.
• Ensuring that sales teams and agents comply properly with regulatory and organizational compliance to maintain a balance between business volume and quality.
• Issues tracking sales personnel who leave before complaints are lodged.
• Maintaining alignment with a fast-changing regulatory landscape and competitive market conditions.

Key Responsibilities

• Assist by assessing procedures, policies, and processes across New Business, Underwriting, and Claims functions for compliance risks specific to assigned operational verticals.
• Identify operational compliance risks, report findings, and recommend corrective actions to management.
• Monitor assigned operational units’ activities and help design decentralized compliance controls.
• Help implement preventive and corrective measures in operational processes and procedures.
• Perform retrospective audits on sample policies received from operational units, analyze results, and propose improvements for process strengthening.
• Conduct mystery shopping initiatives at empaneled medical centers and company branches nationwide to detect fraud.
• Implement system checks and monthly black box audits to assess business quality underwritten by Aura, preparing detailed reports and offering recommendations.
• Analyze claims data, including surrender and partial withdrawal cases, to identify patterns and develop stricter controls.
• Assist in conducting open and discreet verifications in collaboration with Underwriting and Claims teams, ensuring report circulation within specified timelines.
• Maintain and assist in generating comprehensive MIS reports and provide necessary data and recommendations to senior management as required.