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

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

Reporting structure:

Reports to – DCMO

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: Solid understanding of treatment protocols, claims, and pre-authorization processes.
- Behavioral Skills: Ethical approach, decision-making, analytical thinking, attention to detail, teamwork, communication, and reliability.

📌 DMO- Cuddalore District - Risk & Audit (Tamil Nadu)
🏢 Vidal Health Insurance TPA
📍 Tamil Nadu