Medical Assessor

Claims Associate MedicalCompany: GoDigit General InsuranceDepartment: Health Claims – MedicalPosition OverviewLooking to leverage your medical expertise in a dynamic insurance environment? As a Claims Associate – Medical, you will play a key role in ensuring the accuracy, quality, and integrity of health claims decisions by applying clinical knowledge, regulatory awareness, and strong attention to detail. This role demands a balance of technical understanding and operational execution.Key ResponsibilitiesClaims Processing: Review, analyze, and process health claims accurately and within turnaround time (TAT) as per internal SOPs and regulatory norms.Medical Review: Assess the clinical validity of diagnoses, treatments, and procedures in submitted claims, ensuring appropriate application of medical protocols and coding.Fraud Detection: Identify anomalies, patterns of abuse, or suspicious activities and escalate for investigation or mitigation.Regulatory Compliance: Ensure all claim decisions adhere to health insurance regulations and company policies.Policy Interpretation: Interpret product terms and policy coverage to determine admissibility and guide fair settlement decisions.RequirementsExperience:2–5 years of experience in health claims processing with a clinical/medical backgroundExposure to health insurance processes is essentialEducation: Graduate in any of the following streams: BHMS, BAMS, BDSCertifications: Not mandatoryTechnology Tools: Working knowledge of Microsoft Office Suite (Excel, Word, Outlook)Behavioral TraitsCommunication: Clear and structured communication to convey claim decisions and seek clarificationsAssertiveness: Confidence in decision-making and escalation where neededProactiveness: Initiative in identifying trends, inconsistencies, and continuous process improvementsWhy This Role MattersAs a medical professional in the health claims domain, your assessments are critical to ensuring fair claim outcomes, detecting inefficiencies, and protecting customer trust. You'll be the clinical backbone in a process that balances customer care and operational excellence.Be a part of a team where medical judgment meets insurance precision.