Medical Officer

3 days ago

Gurugram, India Policybazaar for Business Full time

Position: Medical Officer (Doctor) - TPA for Insurance and Risk Analysis

Location: Gurgaon

Job Type: Full-time


Job Overview:

We are seeking a qualified and experienced Medical Officer (Doctor) to join our team at Policybazaar for Business. This role involves using medical expertise to assist in evaluating insurance claims, conducting risk analysis, and ensuring that the medical aspects of claims are handled in accordance with industry standards and regulations. The ideal candidate will have a strong background in healthcare and an understanding of insurance policies and risk management in the medical field.


Key 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.


Risk Assessment and Management:

  • Perform risk assessments based on medical data and historical trends to help evaluate and manage potential risks for both policyholders and insurers.
  • Analyze patient medical history and treatment plans to identify high-risk cases and potential fraud.
  • Collaborate with the underwriting team to provide insights into risk factors and potential areas of concern in the policyholder pool.


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.


Policy Development and Compliance:

  • Assist in the development of health insurance policy guidelines to ensure they are medically sound and compliant with regulatory standards.
  • Stay up-to-date with the latest medical trends, technologies, and regulations to ensure policies reflect current medical practices.
  • Ensure compliance with healthcare laws and insurance industry regulations during the claims processing and risk evaluation stages.


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.


Requirements:


Educational Qualifications:

  • Medical degree (MBBS, MD, or equivalent) from a recognised institution.
  • Relevant specialisation (preferred) is a plus (e.g., General Medicine, Surgery, etc.).


Experience:

  • Minimum of 6 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.


Skills:

  • Strong understanding of medical terminology, clinical procedures, and healthcare protocols.
  • Ability to assess medical documents, interpret medical records, and determine the legitimacy of medical claims.
  • Analytical skills for risk assessment and decision-making.
  • Good communication skills to explain medical matters to non-medical professionals (e.g., insurance teams).
  • Ability to handle sensitive information and ensure confidentiality.


Other Requirements:

  • Strong attention to detail and accuracy.
  • Ability to work under pressure and meet deadlines.
  • Proficiency in MS Office and other healthcare-related software.
  • Knowledge of medical billing and coding standards (ICD, CPT) is an advantage.

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