Medical Officer

Purpose of role:

To scrutinize and process the claims within the agreed TAT by having an understanding of the policy terms & conditions while applying their domain medical knowledge.

Roles and Responsibility

• Check the medical admissibility of a claim by confirming the diagnosis and treatment details.
• Scrutinize the claims, as per the terms and conditions of the insurance policy
• Interpret the ICD coding, evaluate co-pay details, classify non-medical expenses, room tariff, capping details, differentiation of open billing and package etc.
• Understand the process difference between PA and an RI claim and verify the necessary details accordingly.
• Verify the required documents for processing claims and raise an IR in case of an insufficiency.
• Approve or deny the claims as per the terms and conditions within the TAT.
• Handle escalations and responding to mails accordingly

Key Results and Outcomes driven by this role:

• Error-free processing (100% Accuracy)
• Maintaining TAT
• Productivity (Achieve the daily targets)

Technical Competencies & Behavioral competencies:

• Analytical Skills
• Basic Computer knowledge
• Type writing skills
• Communication skills
• Decision Making