Medical Officer

• Core Responsibilities

1. Forensic Medical Document Review

Chart Audit: Conduct deep-dive reviews of hospital Indoor Case Papers (ICP), nursing notes, temperature charts, doctor order sheets, and laboratory or radiological data.

• Discrepancy Identification: Analyze files for indicators of health insurance fraud, abuse, or misrepresentation—such as inflated billing, phantom treatments, discrepancies in length of stay, or artificial active line-of-treatment setups.
• PED Evaluation: Examine historic medical records to check for non-disclosure of Pre-Existing Diseases (PED) by analyzing the chronology and presentation of chronic ailments.
• 2. Expert Medical Reporting & DraftingReport Synthesis: Translate complex forensic field findings, patient interviews, and treating doctor statements into clearly structured, professional medical-legal reports.
• Clinical Justification: Formulate a objective, evidence-based medical opinion regarding the genuineness and clinical validity of the admission and treatment.
• Template Utilization: Ensure all findings are systematically formatted into the company’s internal reporting layouts, tracking milestones clearly for insurance clients (such as Zurich Kotak, Aditya Birla, or Go Digit).
• 3. Cross-Functional CoordinationField Support: Act as a central medical advisor to Field Insurance Claim Verification Executives, providing technical clarity on what hospital documents or treating doctor queries to pursue on-site.
• Client Communication: Draft authoritative technical letters or summaries outlining the grounds for claim validation or recommended repudiation based on insurance guidelines and medical evidence.
• Job Requirements & QualificationsEducation: A professional degree in alternative or conventional medicine—BAMS, BHMS, BUMS, BDS, or an MBBS graduate with a strong clinical foundation.
• Domain Knowledge: Solid grasp of clinical terminologies, pharmacology, standard treatment protocols for acute and chronic conditions, and IRDAI health insurance guidelines.
• Core Skills:
• Analytical Ability: High proficiency in spotting data mismatches between real-world clinical status and paper documentation.
• Written Communication: Fluent, grammatically accurate written English is essential for drafting legally and medically sound corporate reports.
• Tech Literacy: Comfort using workplace collaboration tools (such as advanced spreadsheet filters and document automation software) to maintain real-time operational trackers.
• Key Performance Indicators (KPIs)Turnaround Time (TAT): Delivering completed, proofread medical opinion reports within strict client service-level agreements (SLAs).
• Report Accuracy: Minimizing technical or typographical errors in finalized templates.
• Savings Realization: Accurately identifying non-genuine or inflated claims to protect client risk portfolios.