Medical Officer|Health Claims

The 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

• Claims Review & Adjudication
• Review and validate pre-authorization and reimbursement claims based on medical necessity, clinical appropriateness, and policy terms.
• Assess diagnostic reports, prescriptions, discharge summaries, and medical records for accuracy and completeness.
• Ensure claims decisions are aligned with IRDAI regulations and company policy.
• Pre-Authorization & Approvals
• Evaluate pre-authorization requests within agreed turnaround times.
• Liaise with treating doctors/hospitals to seek additional clinical information when required.
• Fraud & Abuse Prevention
• Identify potential fraudulent or exaggerated claims by analyzing treatment patterns and discrepancies.
• Support field investigation teams with medical opinion.
• Compliance & Documentation
• Maintain accurate, confidential, and complete documentation for all cases handled.
• Ensure compliance with industry regulations, ethical standards, and company SOPs.

Qualifications & Skills

• Education:BAMS/BDS/BHMS/BYMS/BSMS
• Experience: 2–5 years of clinical practice; prior experience in health insurance, TPA, or claims management is an advantage.
• Knowledge:
• Good understanding of clinical procedures, hospital billing, and ICD coding.
• Familiarity with IRDAI guidelines and medical insurance processes.
• Skills:
• Strong analytical and decision-making skills.
• Excellent written and verbal communication.
• Ability to work in a fast-paced, process-driven environment.

Job Types: Full-time, Permanent

Pay: ₹20,000.00 - ₹25,000.00 per month

Work Location: In person