Walk-in || Medical Officer

Role & responsibilities

Job Description Medical officer

Department: Cashless
Designation: Executive / Senior Executive Claims Operations
Location: Jaipur, Rajasthan
Reporting To: Manager Cashless

Job Purpose

To efficiently process and manage assigned claims within defined productivity and quality standards while ensuring accuracy, compliance, and minimum financial errors. The role will focus on achieving productivity targets, maintaining high-quality claim processing, reducing short-paid cases, and continuously improving SF% through accurate assessment and adherence to established processes and guidelines.

Key Responsibilities

1. Productivity & Claims Processing 50%

• Process assigned claims within defined productivity and turnaround time requirements.
• Achieve daily, weekly, and monthly productivity targets as per the defined benchmarks.
• Maintain consistent productivity without compromising processing accuracy and quality.
• Prioritize cases based on business requirements, TAT, complexity, and ageing.
• Monitor individual productivity against assigned targets and identify areas for improvement.
• Ensure timely completion and closure of assigned cases.
• Maintain accurate records and update claim status in the relevant systems.
• Support the team in achieving overall operational productivity targets.

2. Quality & Concurrent Audit 10%

• Process claims accurately in accordance with defined policies, SOPs, and operational guidelines.
• Ensure zero financial errors in claim processing.
• Review claim details, eligibility, deductions, calculations, and supporting documents before final processing.
• Understand and address observations raised during concurrent audits.
• Analyze recurring errors and implement corrective measures to prevent repetition.
• Maintain a high level of accuracy while meeting productivity targets.
• Ensure adherence to internal controls and financial approval guidelines.

3. Short-Paid Cases / NME Reduction – 15%

• Analyze short-paid cases and identify the reasons contributing to NME (Non-Medical Expenses) related short payments.
• Ensure accurate application of policy terms, limits, deductions, and non-medical expense rules.
• Minimize avoidable short-paid cases through accurate claim assessment and processing.
• Review previous short-paid cases and identify recurring error patterns.
• Coordinate with relevant teams for clarification and resolution of claim-related discrepancies.
• Contribute towards quarter-on-quarter reduction in short-paid cases.
• Work towards achieving the defined improvement benchmarks, including up to 40% reduction over the previous quarter.

4. SF% Management & Quality Improvement – 15%

• Monitor and control SF% through accurate claim assessment and adherence to process guidelines.
• Identify the key reasons contributing to SF% and take corrective actions.
• Analyze trends and recurring issues impacting SF% performance.
• Ensure appropriate documentation and validation before claim processing.
• Coordinate with concerned teams to resolve process gaps affecting SF%.
• Contribute towards continuous improvement in SF% as per defined quarterly targets.
• Maintain consistency in claim decisions while balancing productivity and quality.