Doctor

Key Responsibilities:

Medical Claims Review:

Analyze and assess pre-authorization and post-treatment reimbursement claims.

Review medical records, diagnosis, investigation reports, and treatment plans to ensure clinical appropriateness and policy alignment.

Validate claims based on insurance policies, internal guidelines.

Decision Making:

Determine the admissibility or rejection of claims and recommend the claim amount.

Coordinate with claims team and finance for timely claim settlements.

Communication & Coordination:

Liaise with hospitals, policyholders, and internal teams to clarify documentation or medical details.

Provide medical inputs to customer support or grievance redressal teams when needed.

Documentation & Reporting:

Maintain accurate and updated documentation of all reviewed cases.

Support audit and compliance processes by ensuring claims are processed with proper medical justification.

Quality & Compliance:

Ensure adherence to TATs (Turn Around Times) and SLAs (Service Level Agreements).

Maintain confidentiality and handle sensitive health data in compliance with data protection regulations.

Required Qualifications & Experience:

Education: MBBS / BAMS / BHMS / BDS (depending on organizational policy)

Experience: 1–5 years in health insurance, TPA, or hospital claims processing preferred.

Licenses: Valid medical registration with relevant council.

Skills & Competencies:

Strong understanding of medical terminology, clinical procedures, and healthcare systems.

Knowledge of health insurance policies, ICD/CPT coding, and regulatory norms (IRDAI).

Analytical thinking and attention to detail.

Good written and verbal communication skills.

Proficiency in MS Office and claims processing software.

Job Type: Full-time

Pay: ₹80,000.00 - ₹100,000.00 per month

Work Location: In person