We are Hiring Medical officer for our Claims Team at our Registered Coimbatore Office.

Year of Experience : 2 to 5 Years

Industry : TPA / Health Insurance

Roles & Responsibilities
- Processing of health insurance claims submitted by policyholders, hospitals, or healthcare providers.
- Get fully trained and understand claims software, functionality and validations.
- Verify whether the claim falls within the coverage/ scope of the health insurance policy.
- Check medical details in the claim documents and determine admissibility of the claim.
- Examine medical records, diagnostic reports, treatment plans, and other relevant documents to verify the authenticity and medical necessity of the services claimed.
- Check for pre-existing conditions, policy exclusions, waiting periods, and any other relevant policy provisions.
- Coding of ailments /procedures as per the regulatory requirement of coding the ailments/diseases/ procedures
- Validate the accuracy billing information submitted in the claims to prevent fraudulent or inflated billing.




- Evaluate the medical necessity of the treatments or procedures claimed, considering standard medical guidelines and best practices.
- Raising appropriate queries to hospitals, doctors, other healthcare providers and members to gather additional information or clarify details related to the claims.
- Be vigilant in identifying potential fraudulent claims and report them to the appropriate authorities for further investigation.
- Make informed decisions regarding the approval, partial approval, or denial of insurance claims based on the medical assessment and policy terms and conditions.
- Maintain a high level of accuracy and quality in claims processing to ensure customer satisfaction and adherence to regulatory standards.
- Help and support to other team members in billing, quality check, CRM, CS and contact center to clarify customer queries satisfactorily.
- Stay up-to-date with relevant healthcare laws, regulations and indust

📌 Medical Officer (Gandhipuram)
🏢 Link K Insurance TPA
📍 Gandhipuram