Job Title: Medical Claim Investigator

Job Description:

Location: Delhi NCR , Lucknow

Position Overview: As a Medical Claim Investigator, you will play a crucial role in evaluating and investigating medical insurance claims to ensure accuracy, compliance, and fair reimbursement. This position requires a strong understanding of medical terminology, healthcare procedures, and insurance policies. The primary focus is on medico profiles, involving thorough investigation and analysis of medical documentation to determine the legitimacy of claims.

Claims Verification:

·        Review and assess medical claims to verify accuracy and completeness.

·        Confirm that all submitted documentation aligns with the provided information and complies with relevant policies.

·        Medical Record Analysis:

·        Analyze medical records and reports to validate the necessity and appropriateness of medical treatments and procedures.

·        Ensure that the medical services claimed are in line with accepted standards and guidelines.

·        Fraud Detection:

·        Identify potentially fraudulent activities by scrutinizing claim details, medical records, and billing information.

·        Collaborate with fraud detection units to investigate suspicious claims and report findings.

·        Policy Adherence:

·        Ensure that all claims adhere to the company's policies and procedures, as well as industry regulations.

·        Provide recommendations for policy improvements based on claim investigation findings.

·        Communication:

·        Communicate effectively with healthcare providers, claimants, and internal teams to gather additional information or clarification on claims.

·        Document all communication and investigation findings for reference and auditing purposes.

·        Reporting:

Prepare detailed reports summarizing claim investigation results, including any discrepancies, fraudulent activities, or policy violations.

Present findings to relevant stakeholders and contribute to decision-making processes.Continuous Improvement:

Stay updated on medical and insurance industry trends, regulations, and best practices.

Propose and implement process improvements to enhance the efficiency and effectiveness of claim investigation procedures.

Kindly Share your Resume to Kashvi Thakkar

Kashvi.talish@gmail.com \ 9313160010