Case Management & Medical Audit - Bangalore

Job Description : Lead Case Management & Medical Audit

• Location: Bangalore
  
• Experience: 4–8 Years (Clinical Audit, Medical Case Management, TPA Claims Audit)
  
• Role Summary: Drive clinical audit processes, review high-value or complex claims, and lead real-time and post-facto price negotiations with provider hospitals to optimize claims spending for partner insurers.
  
• Key Responsibilities:
  
• Perform clinical and financial audits on targeted hospital claims to identify billing discrepancies, unbundling, or tariff non-compliance.
  
• Negotiate directly with hospital management for discounts on high-cost cases, non-tariff procedures, and length-of-stay (LOS) optimizations.
  
• Establish audit guidelines, medical necessity protocols, and tariff adherence frameworks.
  
• Collaborate with the insurer's claims processing team to share findings, fraud trends, and cost-containment insights.
  
• Qualifications & Skills:
  
• Medical degree (MBBS, BAMS, BHMS) or Master’s in Hospital Administration (MHA) / Public Health (MPH).
  
• Hands-on experience in medical auditing, utilization review, or claims management in an insurance/TPA environment.
  
• High medical-legal literacy and strong financial negotiation capability.

Thanks & Regards

Hariprasad