Medical Reviewer

Job Description

REQUIREMENTS

• Medical Degree (MBBS or equivalent) from a school recognized by the WHO.
• 2-3 years of experience in Medical Claims Evaluation/In-Patient Approvals/Case Management preferably from TPA / MSO organization in Insurance sector.
• Certified Medical Coder (CPT/ICD/DRGs) with relevant experience in DRG debates and Severity negotiations
• Industry knowledge related to local healthcare services system.

RESPONSIBILITIES

• Evaluate and assess the healthcare needs of clients, including reviewing medical records, insurance policies, and treatment plans by active collaboration with healthcare providers and clients.
• Assess risk exposure of members in line with medical underwriting policies.
• Evaluate case to achieve optimum member’s satisfaction, adhere to strict TATs and manage cost-containment via prescribed maneuvers like DRG debates
• Quick and accurate management of queries from Providers, Insurance Companies and Insured members relating to approvals
• Provide medical guidance to the Claims Department staff and assistance in accurate coding, Add-on/LTC reviews.
• Deliver excellent customer service to Insurance Companies and insured members with a view of achieving maximum client satisfaction.
• Case Management/attending hospital visits to investigate claims to minimize fraud and abuse.
• Compile data and prepare monthly statistical reports to monitor departmental performance and medical trends.

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