tpa medical officer

19 hours ago

Gurgaon, Haryana, India ClaimBuddy Technologies Pvt Ltd Full time ₹ 6,55,120 - ₹ 78,62,400 per year

COMPANY

is a MediClaim support company that acts as one-stop solution for claim assistance for Patients and Hospitals.

We are building an ecosystem to ensure hassle-free insurance claims by leveraging technology and a set of simple yet powerful processes and operations.

Job Description: Claim Processing Doctor

Position Overview: As a Claim Processing Doctor in the insurance industry, your primary responsibility is to assess and evaluate medical claims submitted by policyholders or healthcare providers. You will ensure that claims are processed accurately and efficiently according to established guidelines and policies. This role requires a strong understanding of medical terminology, procedures, and billing practices, as well as the ability to make informed decisions based on medical necessity and policy coverage.

Key Responsibilities:

  1. Review and Assessment:

o Evaluate medical claims to determine the validity, accuracy, and completeness of information provided.

o Assess medical necessity based on policy guidelines and medical evidence.

o Verify the authenticity of medical documentation and reports submitted with claims.

  1. Documentation and Record Keeping:

o Document findings, decisions, and actions taken during claim processing.

o Maintain detailed records of each claim reviewed, including correspondence and additional information obtained.

o Ensure compliance with regulatory requirements and internal policies regarding confidentiality and data protection.

  1. Communication and Collaboration:

o Communicate with policy holders, healthcare providers, and internal stakeholders regarding claim decisions and requirements.

o Provide guidance and assistance to colleagues regarding medical terminology, coding, and procedural guidelines.

  1. Quality Assurance:

o Conduct quality reviews of processed claims to ensure accuracy and consistency.

Required Qualifications:

  • Medical degree (MBBS/BAMS/BHMS/BUMS) from an accredited institution.

  • Active medical license in the relevant jurisdiction.

  • Knowledge of medical coding systems (e.g.,ICD-10, CPT)and healthcare billing practices.

  • Attention to detail and accuracy in processing claims.

Preferred Qualifications:

  • Experience in medical claims review or healthcare administration.

  • Familiarity with insurance industry software and claim processing systems.

  • Strong analytical and decision-making skills.

  • Excellent communication and interpersonal skills.

  • Ability to work independently part of a team.

  • Attention to detail and accuracy in processing claims.

Job Type: Full-time

Pay: ₹31, ₹65,512.07 per month

Benefits:

  • Health insurance
  • Provident Fund

Work Location: In person

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