Doctor

Job Overview :

As a TPA Doctor, you will be responsible for reviewing medical claims to assess the necessity of treatments, scrutinizing medical records, and ensuring compliance with insurance policy terms. You will play a pivotal role in the cashless authorization process and in ensuring the accuracy and validity of medical claims. The TPA Doctor will communicate with treating physicians, insurers, and other healthcare professionals to support claims processing, fraud detection, and quality control.

• Key Responsibilities:

1. Review OPD/IPD Claims:

• Thoroughly assess outpatient and inpatient medical claims for their medical necessity, appropriateness of treatments, and adherence to standard clinical practices.

2. Cashless Authorization Process:

Process pre-authorization requests from network hospitals by evaluating the medical necessity of the proposed treatment, aligning it with policy coverage.

• Coordination with Hospitals and Insurers: Collaborate with hospital doctors, billing departments, and insurers to facilitate timely approvals and efficient claim processing.

3. Communication & Coordination :

• Reach out to treating physicians for clarifications regarding medical conditions, treatment protocols, or diagnostic results when necessary.

4. Documentation & Compliance:

Ensure that all medical decisions and the rationale for approving, querying, or rejecting claims are well-documented and stored securely.

• Regulatory Compliance: Adhere to relevant regulatory guidelines, including those set by the IRDAI, and ensure compliance with internal SOPs and medical ethics.
• Confidentiality: Maintain strict confidentiality of patient and policyholder information, in line with privacy laws and organizational policies.

5. Fraud Detection & Quality Control :

Flag claims that appear suspicious or involve high-risk activities for further investigation to detect potential fraud or malpractice.

• Quality Control: Ensure that claims are processed with the highest standards of accuracy and integrity, identifying any areas of improvement for quality enhancement.
• Knowledge: Strong understanding of medical treatments, healthcare protocols, diagnostics, and insurance policies.
• Attention to Detail: Ability to analyze complex medical data and claims documents with precision.
• Communication Skills: Excellent verbal and written communication skills for interacting with healthcare providers, insurance professionals, and policyholders.
• Regulatory Awareness: Knowledge of IRDAI guidelines, healthcare regulations, and privacy laws.
• Confidentiality: Strong sense of confidentiality and professionalism, ensuring patient data is handled securely.

Preferred Attributes:

• Experience in a TPA or insurance claims processing role.
• Familiarity with health insurance policies and claims adjudication processes.
• Strong organizational and multitasking abilities to manage high volumes of claims.