Senior Medical Officer

JD :Role SummaryWe 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 TPA’s network and hospital teams. - Quality, Compliance & Documentation - Ensure compliance with insurer/TPA SOPs, IRDAI guidelines and Onsurity’s 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) - 5–10 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.

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