Greeting From Link-K Insurance TPA Pvt Ltd We are hiring Medical Officer for our Claims Team at our Kerala office. Job Role: Medical Officer Industry: TPA/Health Insurance Location: Trivandrum, Kerala Qualification: MBBS, BDS, BAMS, BHMS,.. Roles & Responsibilities of Cashless / Claims - Medical Officer / Doctor : Processing of health insurance claims submitted by policyholders, hospitals, or healthcare providers. Get fully trained and understand claims software, functionality and validations. Verify whether the claim falls within the coverage/ scope of the health insurance policy. Check medical details in the claim documents and determine admissibility of the claim. Examine medical records, diagnostic reports, treatment plans, and other relevant documents to verify the authenticity and medical necessity of the services claimed. Check for pre-existing conditions, policy exclusions, waiting periods, and any other relevant policy provisions. Coding of ailments /procedures as per the regulatory requirement of coding the ailments/diseases/ procedures Validate the accuracy billing information submitted in the claims to prevent fraudulent or inflated billing. Evaluate the medical necessity of the treatments or procedures claimed, considering standard medical guidelines and best practices. Raising appropriate queries to hospitals, doctors, other healthcare providers and members to gather additional information or clarify details related to the claims. Be vigilant in identifying potential fraudulent claims and report them to the appropriate authorities for further investigation. Make informed decisions regarding the approval, partial approval, or denial of insurance claims based on the medical assessment and policy terms and conditions. Maintain a high level of accuracy and quality in claims processing to ensure customer satisfaction and adherence to regulatory standards. Help and support to other team members in billing, quality check, CRM, CS and contact center to clarify customer queries satisfactorily. Stay up-to-date with relevant healthcare laws, regulations and industry standards to ensure compliance in claims processing. Give necessary inputs to team leads for enhancement in IT system and better processes. Regular interaction with Provider Network management team and claims investigation teams to give inputs about the billing practices of hospitals for better negotiations, any suspected fraudulent billing practices noticed to red flag providers and suggestion for better internal controls. Interested candidate can send your updated resume to [email protected] Job Types: Full-time, Permanent Pay: ₹30,000.00 - ₹35,000.00 per month Benefits: Provident Fund Schedule: Day shift Work Location: In person
