Medical Officer

Job Title:

Department:

Location:

Reporting To:

Job Overview:

We are looking for a qualified and experienced medical professional to join our insurance operations team to manage and review Group Personal Accident (GPA) and Group Mediclaim (GMC) claims. The role will involve end-to-end medical scrutiny of claims, resolving medical disputes, addressing client grievances, and providing expert support in claim-related discussions with insurers and clients.

Key Responsibilities:

1. Medical Scrutiny of Insurance Claims

• Review and scrutinize GPA and GMC claims from a medical perspective to ensure accuracy, appropriateness, and adherence to policy terms.

2. Handling Disputed / Complex Claims

• Assess and provide opinions on medically disputed claims, especially in cases of:
• Accidental disability
• Death due to medical or accidental causes
• Initial Reviewing the Claims Rejected by the Insurance Company.
• Liaise with insurance company doctors and TPAs to resolve disputes based on clinical merit.

3. Medical Grievance Management

• Address and resolve customer grievances with medical aspects or claim rejections.
• Provide clarifications and justifications in coordination with clients and TPAs to ensure timely resolution.

4. Stakeholder Coordination

• Liaise with corporate clients, insurance company medical teams, TPAs, and legal teams (if needed) for clarity or resolution on medical matters.
• Participate in claim review meetings and offer medical insights to support settlement decisions.

5. Documentation & Compliance

• Maintain detailed and confidential medical case notes for claims handled.
• Ensure all recommendations, approvals, and medical assessments are properly documented and aligned with internal policies and industry regulations.

Required Skills:

• Strong clinical evaluation and documentation review skills
• Good understanding of insurance terms and claims processes (especially GPA & GMC)
• Ability to assess disability and accidental claims from a medico-legal standpoint
• Excellent communication and interpersonal skills for client and insurer coordination
• Problem-solving mindset with attention to medical and procedural details

Qualifications:

• MBBS/BAMS/BHMS; Additional qualifications in insurance or healthcare administration will be an added advantage
• 3–5 years of experience in medical claims review in the insurance or TPA industry
• Familiarity with claim adjudication processes in Group Health and Personal Accident Insurance preferred