Senior Medical Officer

Job Description: Job Title : Senior Medical Officer Investigation Team Department : Investigation Location : [Insert Office Location] Reports To : Head Claims Investigation Employment Type : Full-time Job Purpose: The Senior Medical Officer will lead and support the investigation team by reviewing, evaluating, and investigating health insurance claims to ensure medical appropriateness and detect fraud, waste, or abuse. The Senior Medical Officer will act as a bridge between medical knowledge and investigator, playing a key role in ensuring fair and accurate claim settlements. Key Responsibilities: Evaluate high-value and suspicious claims by reviewing medical documents, patient history, and treatment records. Verify and scrutiny the claim documents. Guide and supervise field medical officers and investigators in collecting and interpreting clinical information. Identify inconsistencies, over-utilization, or fraudulent patterns in medical claims. Handle escalations and responding to mails accordingly. Support legal or compliance teams in preparing medical reports or expert testimony in fraud cases. Assist in preparing MIS reports, audits, and documentation related to claim investigation outcomes. Ensure adherence to IRDAI guidelines and internal medical policy frameworks. Train and mentor junior medical officers and non-medical investigators on claim evaluation practices. Productivity ( Achieve the daily targets ) Maintaining TAT Required Qualifications & Skills: Experience: Minimum 57 years ( in clinical practice and/or health insurance, with at least 2 years in claim Auditing) Strong knowledge of medical procedures, diagnostics, hospital protocols, and insurance norms Excellent analytical and documentation skills Good communication and interpersonal skills to coordinate with medical and non-medical stakeholders Decision Making Analytical Skills Familiarity with health insurance fraud indicators and regulatory compliance Proficiency in using medical claim systems and MS Office tools Industry Type : Insurance Department: Health care & Life Science Education: Preferred Attributes: Prior experience in a health insurance company, TPA, or investigation agency