COE- ILM-Network Audit [Health & EW]

PRINCIPAL ACCOUNTABILITIES Planning and Preparation: Establish an audit team with appropriate expertise and qualifications. Review relevant regulations, guidelines, and company policies related to network empanelment. Develop an audit plan, including the scope, objectives, timelines, and resource allocation. Communicate the audit plan to relevant stakeholders and obtain necessary approvals. Assessment of Existing Processes: Evaluate the existing network empanelment policies and procedures. Review the criteria and process for the selection, onboarding, and monitoring of third-party service providers. Assess the due diligence and background checks conducted on service providers. Verify compliance with regulatory requirements and industry best practices. Sampling and Testing: Select a representative sample of third-party service providers for testing. Review the documentation and records related to the empanelment of the selected service providers. Conduct on-site visits or virtual assessments, as applicable, to validate the information provided. Test the effectiveness of controls and processes related to network empanelment. Reporting and Recommendations: Document the findings, observations, and areas for improvement in a comprehensive audit report. Classify the findings based on their severity and impact. Provide recommendations for addressing identified gaps and enhancing the network empanelment process. Present the audit report to relevant stakeholders and management for review and discussion. MAJOR CHALLENGES Working in a noncooperative and resistive environment may be stressful. Experienced Network auditors with blend of investigative and analytical thinking are rare Knowledge of General insurance industry is limited Rural reach, extensive travelling, facing hostile situations Handling data from multiple sources. Most of these sources use unique data collection methods and formats DECISIONS Shortlisting vendors (Auditors) and Financials payouts Strategic planning & execution to deliver the maximum output from available resources / manpower. Recommendation with regards to process enhancement & Implementation Recommendations to the VH’s on the new opportunities to investigate and prevent frauds / leakages. INTERACTIONS Internal Clients Roles you need to interact with inside the organization to enable success in your day to day work Head of Analytics Head ILM, VH & ILM team members Claim’s, Underwriting, Business, Actuarial, Risk, Audit, HR, Legal, EW etc External Clients Roles you need to interact with outside the organization to enable success in your day to day work Data Analytics Vendors Private detective agencies Field Investigation/Agency Audit Firms Other Dimensions Business process improvement solutions (Leakage / Fraud proof ) Use of analytics towards Fraud Risk assessment Educational Qualifications MBBS / BE in Electronics/Mechanical/automobile/Electricals Professional education in Fraud / Forensic studies / Law / Risk management / Audit Work Experience Knowledge of – Audit, Data analysis, Fraud Risk Management, A minimum of 10 Years of work experience. (with at least 5 years of Fraud risk experience) Interview skills, Content writing skills, Team management skills Show more Show less