Qureos Mentor

Nucleon Health

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 Job Title:
 
 Medical Officer / TPA Doctor
 
 
 
 Reporting To:
 
 CFO
 
 
 &nbsp;
 
 
 
 Job Purpose:
 
 
 
 To evaluate, process, and approve health insurance claims, provide medical opinions, and ensure compliance with policy terms, medical guidelines, and regulatory standards for the TPA.
 
 
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 Key Responsibilities:
 
 
 
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 Claims &amp; Pre-Authorization:
 
 
 - Review and process cashless pre-authorization requests from network hospitals.
 
 
 - Assess medical necessity, diagnosis, treatment plans, and estimated costs.
 
 
 - Approve, query, or deny requests as per policy terms and medical protocols.
 
 
 - Review final bills and discharge summaries for claim settlement.
 
 
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 Medical Evaluation:
 
 
 - Provide medical opinions on hospitalization, procedures, and length of stay.
 
 
 - Identify non-admissible expenses and policy exclusions.
 
 
 - Ensure adherence to standard treatment guidelines (STGs).
 
 
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 Coordination &amp; Communication:
 
 
 - Coordinate with network hospitals, treating doctors, and TPA operations teams.
 
 
 - Clarify medical queries with hospitals for claim processing.
 
 
 - Support customer service teams for medical escalations.
 
 
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 Compliance &amp; Documentation:
 
 
 - Ensure compliance with IRDAI guidelines, insurer policies, and internal SOPs.
 
 
 - Maintain proper medical documentation and audit trails.
 
 
 - Support internal and external audits.
 
 
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 Quality &amp; Fraud Control:
 
 
 - Assist in fraud detection, abuse, and overbilling cases.
 
 
 - Flag suspicious or high-risk claims for investigation.
 
 
 - Participate in claim quality reviews and process improvements.
 
 
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 Qualifications:
 
 
 
 - MBBS, BHMS, BAMS
 
 
 - Valid Medical Council registration (NMC / State Medical Council)
 
 
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 Experience:
 
 
 
 - 1&ndash;5 years of clinical or TPA/insurance experience
 
 
 - Experience in claims processing / pre-authorization is an advantage
 
 
 - Fresh MBBS candidates may be considered for junior roles
 
 
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 Skills &amp; Competencies:
 
 
 
 - Strong knowledge of clinical protocols and medical terminology
 
 
 - Understanding of health insurance policies and claim processes
 
 
 - Good analytical and decision-making skills
 
 
 - Excellent communication and documentation skills
 
 
 - Basic computer knowledge (HIS, TPA portals, MS Office)
 
 
 &nbsp;
 
 
 
 Work Environment:
 
 
 
 - Office-based / Hybrid (as per company policy)
 
 
 - Rotational shifts may apply
 
 
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 Key Performance Indicators (KPIs):
 
 
 
 - Claim turnaround time (TAT)
 
 
 - Accuracy of medical decisions
 
 
 - Compliance and audit scores
 
 
 - Quality of documentation
 
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Medical Officer (TPA Doctor)

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Nucleon Health

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Medical Officer (TPA Doctor)