Medical Officer – TPA Claim Process

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Job Summary:

The Medical Officer (TPA) will be responsible for reviewing, validating, and processing insurance (TPA) claims, ensuring medical accuracy, compliance with policy terms, and timely coordination between hospital departments, doctors, and TPA representatives.

Key Responsibilities:

• Examine and verify patients’ medical records, treatment plans, and discharge summaries for insurance claim processing.
• Coordinate with treating consultants to obtain medical justifications or clarifications required by the TPA.
• Scrutinize pre-authorization and final bill submissions as per TPA and insurance guidelines.
• Ensure correctness of ICD codes, procedures, and diagnosis in the claim documents.
• Review claim queries and prepare appropriate medical responses or justifications.
• Liaise with TPA coordinators, hospital billing, and admission teams to ensure smooth cashless approval and reimbursement flow.
• Maintain accurate claim records and ensure timely submission of documents to TPAs.
• Monitor and track pending and rejected claims, ensuring resolution in coordination with the TPA team.
• Ensure compliance with TPA policies, medical ethics, and hospital protocols.
• Provide medical support to the TPA operations team for claim audits and reconciliation.

Required Qualifications & Skills:

• MBBS / BHMS / BAMS / equivalent medical qualification (MCI-registered preferred).
• 1–3 years of experience in hospital TPA claim processing or medical audit.
• Sound knowledge of health insurance policies, cashless & reimbursement claim processes.
• Strong analytical and documentation skills.
• Proficiency in MS Office and hospital management software (HMS).
• Good communication and coordination abilities.