Medical Officer IPD Claims

Job TitleMedical Officer IPD Claims DepartmentClaims - IPD Reporting ToManager Medical Claims / Claims Head Job SummaryThe IPD Claims Medical Officer is responsible for evaluating inpatient hospitalization claims, ensuring medical necessity, policy compliance, and accurate claim adjudication. The role involves reviewing medical records, coordinating with hospitals and TPAs, identifying fraudulent claims, and ensuring timely claim processing within defined turnaround times (TAT). Key ResponsibilitiesReview and assess IPD cashless and reimbursement claims.Verify diagnosis, treatment, investigations, procedures, and length of hospital stay.Evaluate medical necessity based on clinical guidelines and insurance policy terms.Approve, partially approve, reject, or raise queries for claims with appropriate medical justification.Review pre-authorization, enhancement requests, and discharge approvals.Analyze hospital bills for room rent eligibility, package rates, non-medical expenses, and policy exclusions.Coordinate with hospitals, treating physicians, TPAs, and internal claims teams to obtain additional clinical information.Detect suspicious claims and escalate potential fraud, abuse, or unnecessary hospitalization cases.Ensure compliance with IRDAI guidelines, company SOPs, and claim processing standards.Maintain accurate documentation and medical notes for audit purposes.Achieve defined productivity, quality, and turnaround time (TAT) targets.Support grievance handling and respond to medical claim escalations when required.QualificationsBAMS/BHMS/BDS/BUMS Experience15 years of experience in Health Insurance, TPA, or Medical Claims.Experience in IPD claims adjudication, pre-authorization, or utilization review preferred.Required SkillsStrong clinical knowledge.Understanding of health insurance policies and claims processes.Knowledge of ICD coding and medical terminology.Familiarity with hospital billing practices and package rates.Analytical and decision-making skills.Attention to detail and documentation accuracy.Effective communication and stakeholder management.Proficiency in MS Office and claims management systems.Key Performance Indicators (KPIs)Claims processed within TAT.Medical adjudication accuracy.Quality audit score.Productivity (claims/day).Fraud detection and escalation quality.Compliance with regulatory and internal guidelines.Customer and hospital query resolution. .