Medical Officer|Health Claims

1 day ago


Kadavanthara Kochi Kerala, India Optimus Medical Services Pvt Ltd Full time

The Medical Officer will be responsible for medical assessment and adjudication of health insurance claims, pre-authorization requests, and medical queries. The role involves applying clinical knowledge to ensure accurate decision-making, compliance with regulatory guidelines, and prevention of fraud, waste, and abuse in claims processing.

Key Responsibilities

  • Claims Review & Adjudication
  • Review and validate pre-authorization and reimbursement claims based on medical necessity, clinical appropriateness, and policy terms.
  • Assess diagnostic reports, prescriptions, discharge summaries, and medical records for accuracy and completeness.
  • Ensure claims decisions are aligned with IRDAI regulations and company policy.
  • Pre-Authorization & Approvals
  • Evaluate pre-authorization requests within agreed turnaround times.
  • Liaise with treating doctors/hospitals to seek additional clinical information when required.
  • Fraud & Abuse Prevention
  • Identify potential fraudulent or exaggerated claims by analyzing treatment patterns and discrepancies.
  • Support field investigation teams with medical opinion.
  • Compliance & Documentation
  • Maintain accurate, confidential, and complete documentation for all cases handled.
  • Ensure compliance with industry regulations, ethical standards, and company SOPs.

Qualifications & Skills

  • Education:BAMS/BDS/BHMS/BYMS/BSMS
  • Experience: 2–5 years of clinical practice; prior experience in health insurance, TPA, or claims management is an advantage.
  • Knowledge:
  • Good understanding of clinical procedures, hospital billing, and ICD coding.
  • Familiarity with IRDAI guidelines and medical insurance processes.
  • Skills:
  • Strong analytical and decision-making skills.
  • Excellent written and verbal communication.
  • Ability to work in a fast-paced, process-driven environment.

Job Types: Full-time, Permanent

Pay: ₹20, ₹25,000.00 per month

Work Location: In person


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