Medical Officer (TPA Doctor)

Job Title: Medical Officer / TPA Doctor

Reporting To: CFO

Job Purpose:

To evaluate, process, and approve health insurance claims, provide medical opinions, and ensure compliance with policy terms, medical guidelines, and regulatory standards for the TPA.

Key Responsibilities:

Claims & Pre-Authorization:

- Review and process cashless pre-authorization requests from network hospitals.

- Assess medical necessity, diagnosis, treatment plans, and estimated costs.

- Approve, query, or deny requests as per policy terms and medical protocols.

- Review final bills and discharge summaries for claim settlement.

Medical Evaluation:

- Provide medical opinions on hospitalization, procedures, and length of stay.

- Identify non-admissible expenses and policy exclusions.

- Ensure adherence to standard treatment guidelines (STGs).

Coordination & Communication:

- Coordinate with network hospitals, treating doctors, and TPA operations teams.

- Clarify medical queries with hospitals for claim processing.

- Support customer service teams for medical escalations.

Compliance & Documentation:

- Ensure compliance with IRDAI guidelines, insurer policies, and internal SOPs.

- Maintain proper medical documentation and audit trails.

- Support internal and external audits.

Quality & Fraud Control:

- Assist in fraud detection, abuse, and overbilling cases.

- Flag suspicious or high-risk claims for investigation.

- Participate in claim quality reviews and process improvements.

Qualifications:

- MBBS, BHMS, BAMS

- Valid Medical Council registration (NMC / State Medical Council)

Experience:

- 15 years of clinical or TPA/insurance experience

- Experience in claims processing / pre-authorization is an advantage

- Fresh MBBS candidates may be considered for junior roles

Skills & Competencies:

- Strong knowledge of clinical protocols and medical terminology

- Understanding of health insurance policies and claim processes

- Good analytical and decision-making skills

- Excellent communication and documentation skills

- Basic computer knowledge (HIS, TPA portals, MS Office)

Work Environment:

- Office-based / Hybrid (as per company policy)

- Rotational shifts may apply

Key Performance Indicators (KPIs):

- Claim turnaround time (TAT)

- Accuracy of medical decisions

- Compliance and audit scores

- Quality of documentation