Job
Description
Medical Officer – Medical Audit & Fraud
1. Job Summary
We are seeking a meticulous and analytical medical professional (BAMS/BHMS/BUMS) to join our Fraud Control and Claims Investigation team. This is a non-clinical, role crucial for analysing the Health Insurance Claim documents.
The Medical Officer will act as the key clinical expert, responsible for applying medical knowledge to detect, investigate, and report on suspected cases of health insurance fraud, waste, and abuse (FWA). You will be the primary link between our data analytics team, on-ground investigators, and the claims processing unit, using your expertise to scrutinise medical records, validate the medical necessity of treatments, and identify aberrant billing patterns from network and non-network providers.
2. Key Responsibilities
Clinical Claims Review:
Conduct in-depth medical reviews of high-value and suspicious claims flagged by the system, TPAs (Third-Party Administrators), or analytics team.
Scrutinise admission notes, treatment protocols, diagnostic reports, and discharge summaries to validate the diagnosis and medical necessity of services rendered.
Assess the appropriateness of the length of stay (ALOS) and the justification for high-cost consumables, medicines, or implants.
Fraud Detection & Analysis:
Apply clinical knowledge to identify red flags and patterns of potential fraud. This includes, but is not limited to:
Unbundling: Billing for services separately that are typically part of a package (e.g., GIPSA PPN packages).
Upcoding: Inflating the severity of an illness or billing for a more complex procedure than was performed.
Lack of Medical Necessity: Performing investigations or procedures not clinically justified by the patient's diagnosis.
Provider Collusion: Identifying patterns suggesting collusion between providers and policyholders (e.g., fabricated bills, planned "paper" admissions).
Investigation & Reporting:
Collaborate with data analysts to interpret billing data and provide clinical context to aberrant trends.
Work closely with on-ground SIU investigators to guide hospital visits and medical record verification.
Prepare detailed, clear, and objective medico-legal reports and case summaries of investigative findings, forming the basis for claim denial, provider warnings, or legal action.
Stakeholder & Provider Liaising:
Act as the medical point-of-contact for complex queries from the claims and legal teams.
Communicate with medical teams at TPAs to ensure alignment on fraud detection policies.
Engage directly with hospital medical teams and doctors to challenge discrepancies, question treatment protocols, and seek clarification on billing.
Compliance & Policy:
Stay updated on IRDAI (Insurance Regulatory and Development Authority of India) anti-fraud guidelines and other relevant regulations.
Assist in developing and refining internal medical audit protocols and fraud trigger rules.
3. Qualifications & Experience
Essential:
Degree: Any recognised medical degree from a recognized institution.
Registration: Must possess a valid and unrestricted registration with the respective councils
Clinical Experience: Minimum of 2-3 years of hands-on clinical experience (e.g., as a Resident Medical Officer, in general practice, or a specific specialty) to provide a strong foundation in clinical decision-making.
Highly Preferred:
Industry Experience: 2+ years of experience in a similar role within a Health Insurance Company or a Third-Party Administrator (TPA).
4. Required Skills & Competencies
Investigative Mindset: A natural curiosity and a "forensic" approach to detail. You must enjoy "connecting the dots" and digging deep into records.
Strong Analytical Skills: Ability to analyse complex medical information alongside financial (billing) data to spot inconsistencies.
Knowledge of Indian Healthcare Ecosystem:
Strong familiarity with Indian hospital billing practices, common treatment tariffs, and surgery packages (e.g., PPN rates).
Understanding of standard medical protocols and treatment costs across different types of hospitals (e.g., multispecialty chains vs. local nursing homes).
Assertiveness & Integrity: High ethical standards and the confidence to challenge senior medical professionals and hospital authorities firmly but professionally.
Excellent Communication: Ability to write clear, concise, and defensible reports for non-medical stakeholders (legal, management).
Tech Savvy: Proficient in MS Office, especially MS Excel, for analysing data and preparing reports. Experience with claims management software is a plus.
