Job Purpose To provide expert medical opinions supporting claims and pre-authorization processes, ensuring compliance with medical, regulatory, and insurer guidelines while maintaining accuracy and ethical standards.

Principal Accountabilities
Review medical documents – Assess records and treatment plans to deliver accurate opinions within defined timelines.
Support decision-making – Guide pre-authorization and claims teams on complex or doubtful cases.
Provide second opinions – Offer expert views to hospitals, doctors, brokers, or customers as required.
Escalate high-risk cases – Refer unresolved or critical cases to CMO within SLA.
Ensure compliance – Maintain records and deliver opinions in line with insurer, company, and IRDAI guidelines.

Reporting structure:

Reports to – Claims Manager

Decisions




Determine medical justification of claims and pre-authorization requests.
Decide on escalation of cases to higher authority.

Interactions

Internal: Pre-authorization team, Claims team, Audit & Compliance.

External: Hospitals, treating doctors, insurers, brokers, customers (for second opinion cases).

Skills & Knowledge
Educational Qualification: MBBS / BAMS / BHMS.
Work Experience: Freshers or doctors with clinical/insurance/TPA experience.
Medical Knowledge: Robust understanding of treatment protocols, claims, and pre-authorization processes.
Behavioral Skills: Ethical approach, decision-making, analytical thinking, attention to detail, teamwork, communication, and reliability.

📌 Medical Officer Part Time Ent Chennai
🏢 Vidal Health Insurance TPA
📍 Chennai