Healthcare Risk Analyst

3 weeks ago


Gurgaon, Haryana, India Policybazaar for Business Full time
Role Summary:

We are seeking a qualified and experienced Healthcare Risk Analyst to join our team at Policybazaar for Business. This role involves utilizing medical expertise to evaluate insurance claims, conduct risk assessments, and ensure that the medical aspects of claims align with industry standards and regulations.

Key Responsibilities:
  • Claims Review and Evaluation:
  • Review medical claims submitted by policyholders to verify accuracy and compliance with insurance policies.
  • Analyze medical documentation provided by hospitals, clinics, and other healthcare providers to determine claim legitimacy.
  • Evaluate the medical necessity of procedures, treatments, and hospital admissions based on insurance policy guidelines.
  • Provide second opinions or consultations on disputed claims or complex medical cases.
  • Risk Assessment and Management:
  • Perform risk assessments using medical data and historical trends to evaluate and manage potential risks for both policyholders and insurers.
  • Examine patient medical histories and treatment plans to identify high-risk cases and potential fraud.
  • Collaborate with the underwriting team to provide insights into risk factors and areas of concern in the policyholder pool.
  • Medical Advisory Services:
  • Offer expert advice and medical guidance to the TPA team, insurance providers, and policyholders regarding medical treatment, diagnoses, and claims.
  • Serve as a liaison between healthcare providers and the insurance company to ensure seamless claims processing and accurate policyholder information.
  • Policy Development and Compliance:
  • Assist in developing 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 claims processing and risk evaluation.
  • Salary and Benefits:
  • This position offers an estimated salary of ₹12,00,000 per annum, commensurate with experience.
  • A competitive benefits package is included, including opportunities for professional growth and development.


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