Medical Officer (Claim Processing)

Role overview

The Medical Officer for claim processing will examine health insurance claims from a medical standpoint. This position focuses on checking clinical records, confirming the authenticity of medical details, and making sure each claim aligns with the policy’s rules and conditions. The role serves as a bridge between medical expertise and insurance workflows so that claim decisions are accurate, fair, and well supported.

Core responsibilities

• Review admission records, discharge summaries, diagnostic reports, and treatment bills to judge whether the treatment was medically necessary and appropriate.
• Check diagnoses, treatment approaches, and hospitalization requirements against accepted medical standards.
• Confirm that claims comply with policy terms such as exclusions, waiting periods, and pre-existing disease clauses.
• Spot suspicious patterns, overstated bills, or inaccurate information in claim submissions.
• Work with hospitals, treating doctors, and insured members to gather clarifications and any missing documents.
• Draft medical opinions, claim notes, and recommendations for approval or rejection.
• Support claims teams by explaining medical terms, clinical relevance, and how policy wording should be interpreted.

Qualifications and requirements

• A BAMS or BHMS degree from a recognized institution.
• Active registration with the relevant medical council.
• Previous exposure to clinical work or medical review is preferred.
• Understanding of health insurance processes and regulatory guidelines will be an added advantage.
• Strong analytical ability to interpret medical records and clinical findings.
• Careful attention to detail to catch inconsistencies in submitted documents.
• Good communication skills to explain medical conclusions to non-medical colleagues.
• Sound knowledge of insurance policy structure, exclusions, and compliance expectations.
• High ethical standards and sound judgment in decision-making.

Role impact

This position helps ensure that genuine claims are settled fairly and transparently, reduces the risk of fraud or inflated claims, and strengthens trust between insured customers and the insurer by upholding medical and ethical standards.

Eligibility

Applicants with BHMS, BAMS, or BNYS qualifications in any specialization may apply, as stated in the sourcing details.