This Job Description (JD) is designed for a senior or specialized role, likely within a TPA (Third Party Administrator) or Health Insurance setup. It emphasizes the "second line of defense" nature of the role—validating claims that have already been processed or quality-checked—and focuses heavily on the analytical and strategic aspects of cost containment.
Job Description: Cost Containment Manager
Job Title: Cost Containment Medical Officer / Medical Auditor
Department: AUDIT & Cost Containment
Location: Bangalore, India
Job Summary
The Cost Containment Medical Officer is a specialized clinical role responsible for the secondary validation of high-value and complex claims, specifically those that have undergone initial Quality Control (QC). This role serves as a critical "gatekeeper" to prevent financial leakage. You will leverage deep medical knowledge of chronic conditions and treatment protocols to audit decisions made by the adjudication team, analyze hospital billing behaviors, and devise data-driven strategies to contain costs without compromising quality of care.




Key Responsibilities
1. Validation of QC’d Claims & Medical Auditing
- Post-QC Validation: Perform secondary clinical reviews on a targeted sample of claims that have already passed the QC stage to identify missed errors, upcoding, or unbundling.
- Complex Case Adjudication: Act as the final escalation point for complex medical cases involving chronic conditions (e.g., diabetes, hypertension, oncology), ensuring treatments align with accepted medical necessity criteria.
- Leakage Detection: Identify systemic failures in the primary adjudication process where "clean" claims are actually resulting in overpayment due to subtle medical nuances.

2. Cost Containment & Guideline Creation
- Guideline Development: Create and update internal Standard Treatment Guidelines (STGs) and adjudication protocols for high-cost diagnoses, aligning them with international standards (e.g., WHO, FDA, NHS) to standardize

📌 Cost Containment-Manager (Bengaluru)
🏢 Vidal Healthcare Services
📍 Bengaluru