Senior Medical Officer

JD :

Role Summary

We are looking for experienced doctors who will independently review, assess and decide health insurance claims (cashless & reimbursement) for the Onsurity portfolio, ensuring fair, fast and accurate claim decisions while protecting both member interests and insurer loss ratios.

Key Responsibilities

• Medical Adjudication & Decisioning
• Evaluate cashless and reimbursement claims (IPD, day-care, high-value cases, complex cases) in line with policy terms, clinical protocols and regulatory guidelines.
• Interpret diagnosis, investigations, treatment plans and line of management to determine whether the claim is medically and contractually admissible.
• Recommend approvals, partial approvals, denials or further queries with clear, well-documented medical reasoning.
• Pre-auth & Discharge Management
• Review hospital pre-auth requests and provide decisions within agreed TATs.
• Handle enhancement requests, discharge approvals and billing disputes in collaboration with TPAs network and hospital teams.
• Quality, Compliance & Documentation
• Ensure compliance with insurer/TPA SOPs, IRDAI guidelines and Onsuritys internal standards.
• Maintain high-quality documentation for every decision, enabling easy audit/tracing.
• Support periodic internal audits and TPA audits with medical justifications as required.
• Fraud Control & Cost Optimisation
• Identify suspicious / potentially fraudulent claims based on medical red flags, patterns and hospital behaviour.
• Recommend investigations, second opinions and enhanced scrutiny where needed.
• Work closely with the claims leadership to support cost control, negotiation and FDE initiatives without compromising genuine member care.
• Stakeholder Collaboration
• Work closely with Onsurity operations, customer support, insurer medical teams, and Vidal teams to resolve complex cases.
• Provide medical clarifications for internal teams and support in drafting member communications where required.
• Participate in case discussions, tri-party reviews and training sessions to continuously improve quality and consistency.
• Process Improvement & Training
• Suggest process improvements, rule refinements and clinical protocols based on recurring patterns.
• Mentor junior medical/claims staff (over time) and contribute to building a strong medical governance culture within Good Doctors.

Desired Profile

• MBBS/BAMS/BHMS or any medical degree from a recognised authority (in Internal Medicine, General Medicine, Family Medicine, Emergency Medicine or related specialities will be an advantage)
• 510 years of total experience with at least 5+ years in health insurance/TPA claims adjudication (cashless and/or reimbursement).
• Solid understanding of:
• Health insurance products & policy wording
• IPD, day-care, surgical procedures, high-cost therapies
• Medical necessity, reasonability, and standard treatment guidelines
• Comfortable working in a high-volume, fast TAT environment with strong attention to detail and documentation.
• Good written and verbal communication skills in English (knowledge of Kannada/Hindi is a plus).
• Strong sense of ethics, fairness and customer centricity able to balance member empathy with prudent risk management.