District Medical Officer jobs

Job description: 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
• Work Location: In person

Pay: ₹20,000.00 - ₹22,000.00 per month

Benefits:

• Flexible schedule
• Paid sick time
• Paid time off

Ability to commute/relocate:

• Kochi, Kerala (Kochi, Ernakulam District): Reliably commute or planning to relocate before starting work (Required)

Education:

• Bachelor's (Preferred)

Language:

• English (Preferred)

Location:

• Kochi, Kerala (Kochi, Ernakulam District) (Preferred)

Work Location: In person