Qureos Mentor

Ocean Group

Job descriptionThe Medical Officer will be responsible for medical assessment and adjudication of health insurance claims, pre-authorization requests, and medical queries. The role involves applying clinical knowledge to ensure accurate decision-making, compliance with regulatory guidelines, and prevention of fraud, waste, and abuse in claims processing.Key Responsibilities<ul><li>Claims Review &amp; Adjudication</li><li>Review and validate pre-authorization and reimbursement claims based on medical necessity, clinical appropriateness, and policy terms.</li><li>Assess diagnostic reports, prescriptions, discharge summaries, and medical records for accuracy and completeness.</li><li>Ensure claims decisions are aligned with IRDAI regulations and company policy.</li><li>Pre-Authorization &amp; Approvals</li><li>Evaluate pre-authorization requests within agreed turnaround times.</li><li>Liaise with treating doctors/hospitals to seek additional clinical information when required.</li><li>Fraud &amp; Abuse Prevention</li><li>Identify potential fraudulent or exaggerated claims by analyzing treatment patterns and discrepancies.</li><li>Support field investigation teams with medical opinion.</li><li>Compliance &amp; Documentation</li><li>Maintain accurate, confidential, and complete documentation for all cases handled.</li><li>Ensure compliance with industry regulations, ethical standards, and company SOPs..</li><li>Allocating claims to field staffs.</li><li>Coordinating the field staffs.</li></ul>Qualifications &amp; Skills<ul><li>Education: BAMS</li><li>Experience: 1&ndash;2 years of clinical practice; prior experience in health insurance, TPA, or claims management is an advantage.</li><li>Knowledge:</li><li>Good understanding of clinical procedures, hospital billing, and ICD coding.</li><li>Familiarity with IRDAI guidelines and medical insurance processes.</li><li>Skills:</li><li>Strong analytical and decision-making skills.</li><li>Excellent written and verbal communication.</li><li>Ability to work in a fast-paced, process-driven environment.</li><li>Looking for female candidates from Trivandrum district only</li></ul>Job Types: Full-time, PermanentPay: &#8377;15,000.00 - &#8377;20,000.00 per monthWork Location: In personJob Type: Full-timePay: &#8377;15,000.00 - &#8377;20,000.00 per monthWork Location: In person

Medical Officer | Health Claims

Join Ocean Group and explore 1   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Ocean Group

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Medical Officer | Health Claims