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.