Job Title
Medical Officer – IPD Claims
Department
Claims - IPD
Reporting To
Manager – Medical Claims / Claims Head
Job Summary
The IPD Claims Medical Officer is responsible for evaluating inpatient hospitalization claims, ensuring medical necessity, policy compliance, and accurate claim adjudication. The role involves reviewing medical records, coordinating with hospitals and TPAs, identifying fraudulent claims, and ensuring timely claim processing within defined turnaround times (TAT).
Key Responsibilities
- Review and assess IPD cashless and reimbursement claims.
- Verify diagnosis, treatment, investigations, procedures, and length of hospital stay.
- Evaluate medical necessity based on clinical guidelines and insurance policy terms.
- Approve, partially approve, reject, or raise queries for claims with appropriate medical justification.
- Review pre-authorization, enhancement requests, and discharge approvals.
- Analyze hospital bills for room rent eligibility, package rates, non-medical expenses, and policy exclusions.
- Coordinate with hospitals, treating physicians, TPAs,



and internal claims teams to obtain additional clinical information.
- Detect suspicious claims and escalate potential fraud, abuse, or unnecessary hospitalization cases.
- Ensure compliance with IRDAI guidelines, company SOPs, and claim processing standards.
- Maintain accurate documentation and medical notes for audit purposes.
- Achieve defined productivity, quality, and turnaround time (TAT) targets.
- Support grievance handling and respond to medical claim escalations when required.

Qualifications
- BAMS/BHMS/BDS/BUMS

Experience
- 1–5 years of experience in Health Insurance, TPA, or Medical Claims.
- Experience in IPD claims adjudication, pre-authorization, or utilization review preferred.

Required Skills
- Solid clinical knowledge.
- Understanding of health insurance policies and claims processes.
- Knowledge of ICD coding and medical terminology.
- Familiarity with hospital billing

📌 Medical Officer IPD Claims (Kochi)
🏢 Vidal Health Insurance TPA
📍 Kochi