Medical Claims Officer jobs

ABOUT THE ROLE

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We are looking for a Medical Officer with strong knowledge of ECHS, CGHS, and third-party administrator (TPA) processes. This is a corporate role focused on medical claims review, pre-authorization, and insurance coordination. The ideal candidate will have 2–6 years of relevant experience and a sound understanding of health insurance operations and medical documentation standards.

KEY RESPONSIBILITIES

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• Review and process health insurance claims under ECHS, CGHS, and other TPA schemes
• Evaluate pre-authorization and enhancement requests with clinical correlation
• Analyze discharge summaries, investigation reports, and treatment records for claim validation
• Verify medical necessity and appropriateness of treatment as per policy and clinical standards
• Identify documentation discrepancies and raise clinical queries with empanelled hospitals
• Coordinate with hospitals, insurers, and internal teams for smooth claim processing
• Ensure compliance with NHA, PMJAY, and Ayushman Bharat guidelines
• Maintain accurate documentation and adhere to defined turnaround time (TAT)
• Stay updated on latest insurance policies, healthcare regulations, and government scheme guidelines

REQUIRED SKILLS & QUALIFICATIONS

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• Ayush or BAMS degree (registered practitioner preferred)
• Minimum 2–5 years of experience in TPA, health insurance, or claims review
• In-depth knowledge of ECHS, CGHS, and other TPA / insurance processes
• Strong understanding of medical documentation and claims review standards
• Good analytical ability and sound clinical judgment for claims evaluation
• Accuracy and attention to detail in documentation
• Effective communication and coordination skills

PREFERRED EXPERIENCE

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• Prior experience in a TPA company, insurance firm, or health insurance desk
• Hands-on experience with PMJAY / Ayushman Bharat claim processing
• Knowledge of ECHS / CGHS empanelment norms and billing procedures
• Familiarity with NHA protocols and government health scheme guidelines

BENEFITS

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• Salary up to ₹8,00,000 per annum (based on experience)
• Paid time off
• Growth opportunity in the health insurance and TPA sector

JOB DETAILS

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• Job Type: Full-Time
• Work Location: In-Person (On-site)

Pay: Up to ₹800,000.00 per year

Benefits:

• Life insurance
• Paid time off

Work Location: In person