Job Summary

We are looking for qualified and experienced medical professionals for the position of TPA Doctor Claims Adjudication. The candidate will be responsible for reviewing and evaluating health insurance claims from a medical perspective, ensuring policy compliance, medical necessity, and accurate claim assessment as per established guidelines.

Role & responsibilities

1. Review and medically evaluate health insurance claims, including cashless and reimbursement claims.
2. Assess medical records, prescriptions, investigation reports, discharge summaries, and treatment details.
3. Evaluate the medical necessity and appropriateness of hospitalization, procedures, and treatments.
4. Verify claims against policy terms, coverage conditions, exclusions, and applicable guidelines.
5. Identify discrepancies,



non-payable items, and potential medical irregularities in claims.
6. Provide medical opinions and recommendations for claim approval, partial approval, or rejection, as per delegated authority and policy guidelines.
7. Coordinate with claims processing teams, hospitals, insurance companies, and other stakeholders for claim clarification.
8. Review high-value, complex, and exceptional claims and provide appropriate medical inputs.
9. Ensure adherence to defined Turnaround Time (TAT) and quality standards.
10. Maintain proper documentation and records of medical claim assessments.

📌 TPA Doctor (Claim Adjudication) (Jaipur)
🏢 Alankit
📍 Jaipur