Job description: 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
- Work Location: In person
Pay: ₹20,000.00 - ₹22,000.00 per month
Benefits:
- Flexible schedule
- Paid sick time
- Paid time off
- Work from home
Ability to commute/relocate:
- Kochi, Kerala (Kochi, Ernakulam District): Reliably commute or planning to relocate before starting work (Required)
Education:
Language:
Location:
- Kochi, Kerala (Kochi, Ernakulam District) (Preferred)
Work Location: In person
