01Key Responsibilities
Claims Review and Evaluation:
Review medical claims submitted by policyholders to ensure accuracy and compliance with insurance policies.Analyze the medical documentation provided by hospitals, clinics, and other healthcare providers to determine the legitimacy of claims.Assess the medical necessity of procedures, treatments, and hospital admissions as per the insurance policy guidelines.Provide second opinion or consultation on disputed claims or complex medical cases.
Medical Advisory Services
Provide expert advice and medical guidance to the TPA team, insurance providers, and policyholders regarding medical treatment, diagnoses, and claims.Act as a liaison between healthcare providers and the insurance company to ensure a seamless claims process and accurate policyholder information.
Medical Audits and Reports
Conduct medical audits to ensure the accuracy of claims and prevent fraud.Prepare detailed reports regarding the medical aspects of claims, risk assessments, and policy compliance for senior management and insurers.
Collaboration with Medical Providers
Communicate with healthcare providers, hospitals, and clinics to clarify medical information and ensure proper documentation is available for claims processing.Collaborate with medical professionals in cases of complex treatments or potential discrepancies between claimed and provided medical services.
Educational Qualifications
Medical degree (MBBS, MD, or equivalent) from a recognized institution.Relevant specialization (if any) is a plus (e.G., General Medicine, Surgery, etc.).
Experience
Minimum of 5 years of experience in the healthcare industry, ideally in a clinical or insurance-related environment.Experience with medical claims evaluation, health insurance, or risk management is highly desirable.Familiarity with healthcare laws, regulations, and insurance policies is a plus. .
