Medical Officer - Medical Claim Audit

Job Description

About Navi Navi is one of the fastest-growing financial services companies in India providing Personal & Home Loans, UPI, Insurance, Mutual Funds, and Gold. Navi's mission is to deliver digital-first financial products that are simple, accessible, and affordable. Drawing on our in-house AI/ML capabilities, technology, and product expertise, Navi is dedicated to building delightful customer experiences. Founders: Sachin Bansal & Ankit Agarwal Know what makes you a Navi_ite : 1. Perseverance, Passion and Commitment Passionate about Navis mission and vision Demonstrates dedication, perseverance, and high ownership Goes above and beyond by taking on additional responsibilities 2. Obsession with high-quality results Consistently creates value for the customers and stakeholders through high-quality outcomes Ensuring excellence in all aspects of work Efficiently manages time, prioritizes tasks, and achieves higher standards 3. Resilience and Adaptability Adapts quickly to new roles, responsibilities, and changing circumstances, showing resilience and agility Key Responsibilities: Review submitted health claims for accuracy, completeness, and compliance with insurance policies and applicable regulations Reviewing and evaluating medical claims to determine their eligibility for payment Investigating medical claims to identify fraud Making decisions about medical claims, such as whether to approve or deny a claim Negotiate with the treating doctor/ hospital in reducing the un-justified hospitalization cost Automate system and bring in improvements on claims processes Monitoring systems and processes to ensure sustained levels of performance Liaison with internal stakeholder to ensure the deadline of TAT’s and SLA’s & Work towards Designated Tasks Tracking of customer communication for effective grievance resolution within TAT & SLA’s Compliance- Through knowledge of products, regulations, guidelines is must to ensure process compliance all the time. Claim Analytics- Periodical claim analysis to identify frauds, monitor claim performance metrics. Informing the customer about the rejection of their claim through call Involves identifying discrepancies, fraud, or errors in claims to ensure compliance with health insurance policies and regulatory requirements What are some of the good to have skills for this role? Medical Graduate in any stream (MBBS/BHMS/BAMS/BUMS/BDS) Experience in handling audit Background in claims processing with clinical experience in a hospital setting Data analytics experience would be an added advantage Ability to handle independent assignments & having the acumen to take logical conclusions Should have a broad understanding of Claims Practice Sharp business acumen to understand health insurance claim servicing needs Excellent communication skills, including writing reports and presentations Ability to anticipate potential problems and take appropriate corrective action Knowledge of health regulations, IRDA circulars is a must. Knowledge of different languages would be an added advantage. Proficiency in Hindi and English is mandatory.