We are seeking a qualified and experienced Medical Officer - Audit/Adherence to join our dynamic team. The ideal candidate will be responsible for reviewing, analyzing, and auditing health insurance claims from a medical perspective to ensure accuracy, compliance, and appropriateness of billed services and also ensure that providers adhere to contract.This role requires a keen understanding of medical conditions, health insurance policies, and the ability to collaborate with both medical professionals and insurance teams. Key Responsibilities: Claims Review and Audit: Conduct comprehensive audits of health insurance claims to ensure they meet company guidelines, industry standards, and regulatory requirements. Review medical records Verify the medical necessity of services rendered and assess the appropriateness of claims based on medical guidelines. Review the claims audited by Insurance companies and help in preparing appropriate response Billing Analysis: Ensure ethical practices are followed and identify any discrepancies between billed charges and approved services wrt to hospital SOC Compliance Monitoring/Adherence Ensure that all health insurance claims adhere to local, state, and healthcare and insurance regulations Monitor claims for potential fraud, waste, or abuse and report discrepancies to the appropriate department. Ensure that providers are adhering to the contract and billing is done as per SOC/packages agreed Collaboration with Stakeholders: Work closely with internal teams such as claims,provider contracting , and Investigations departments to resolve claim-related issues. Liaise with provider contracting teams and healthcare providers and facilities to obtain necessary documentation for claim validation. Reporting & Documentation: Maintain detailed records of claim audits and provide reports on audit findings, recommendations, and actions taken. Prepare reports for management on trends, audit performance, and areas for improvement. Training and Guidance: Provide guidance and training to internal teams on billing abuse, claim processes, and compliance issues. Assist in the development of training materials to promote adherence to proper claims auditing protocols. Continuous Improvement: Identify opportunities for process improvement within the claims auditing workflow. Stay up-to-date with the latest medical trends, and insurance regulations to ensure best practices in the claims audit process. Qualifications: Education: Medical degree (MBBS, or equivalent) or an equivalent healthcare-related qualification. Additional certifications in medical coding ,project management,health insurance etc.would be highly advantageous Experience: Minimum of 2-3 years of experience in a medical claims auditing role or a related field such as health insurance claims, healthcare administration. Strong experience with reviewing and auditing claims, medical records Familiarity with Excel and basic analytics Experience in hospital billing and health insurance claims Skills & Competencies: Strong understanding of medical terminology and healthcare billing practices. In-depth knowledge of health insurance policies, regulations, and compliance requirements Analytical mindset with strong attention to detail and problem-solving abilities. Ability to communicate effectively with medical providers, insurance teams, and other stakeholders. Excellent organizational skills and the ability to manage multiple tasks and deadlines. Personal Attributes: High level of integrity and professionalism. Ability to work independently and as part of a team. Strong interpersonal and communication skills.
