medical officer-non clinical

POSITION: MEDICAL OFFICER PA/RI APPROVER
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.
Designation
Medical Officer
Claims PA/RI Approver

Reporting to
Location
Assistant Manager Claims
Noida
Educational
Qualification
BHMS, , BAMS

Shift

Rotational Shift (for female employee shift ends at 8:30
PM)
6 rotational week offs Provided per month
Week offs
Related courses
attended
None
Management Level
Junior Management Level
Industry Type
Hospital/TPA/Healthcare/Insurance
Roles and
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.
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Responsibilities
Understand the process difference between PA
and an RI claim and verify the necessary details
accordingly.
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Verify the required documents for processing
claims and raise an IR in case of an insufficiency.
Coordinate with the LCM team in case of higher
billing and with the provider team in case of non-
availability of tariff.
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Approve or deny the claims as per the terms and
conditions within the TAT.
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Handle escalations and responding to mails
accordingly.
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Error-free processing (100% Accuracy)
Maintaining TAT
Productivity (Achieve the daily targets)
Key Results and Outcomes
driven by this role:
0- 5 years
Relevant Experience
No of years of experience
0-5 years
None
Demonstrated abilities if
any
Technical Competencies
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Analytical Skills
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Basic Computer knowledge
Type writing skills
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Communication skills
Decision Making
Behavioral competencies