Medical Officer - Medical Claim Audit

About Navi

Navi is one of the fastest-growing financial services companies in India providing Personal & Home Loans, UPI, Insurance, Mutual Funds, and Gold. Navi's mission is to deliver digital-first financial products that are simple, accessible, and affordable. Drawing on our in-house AI/ML capabilities, technology, and product expertise, Navi is dedicated to building delightful customer experiences.

Founders: Sachin Bansal & Ankit Agarwal

Know what makes you a Navi_ite :

1. Perseverance, Passion and Commitment

• Passionate about Navis mission and vision
• Demonstrates dedication, perseverance, and high ownership
• Goes above and beyond by taking on additional responsibilities

2. Obsession with high-quality results

• Consistently creates value for the customers and stakeholders through high-quality outcomes
• Ensuring excellence in all aspects of work
• Efficiently manages time, prioritizes tasks, and achieves higher standards

3. Resilience and Adaptability

• Adapts quickly to new roles, responsibilities, and changing circumstances, showing resilience and agility

Key Responsibilities:

• Review submitted health claims for accuracy, completeness, and compliance with insurance policies and applicable regulations
• Reviewing and evaluating medical claims to determine their eligibility for payment Investigating medical claims to identify fraud
• Making decisions about medical claims, such as whether to approve or deny a claim
• Negotiate with the treating doctor/ hospital in reducing the un-justified hospitalization cost
• Automate system and bring in improvements on claims processes
• Monitoring systems and processes to ensure sustained levels of performance
• Liaison with internal stakeholder to ensure the deadline of TAT’s and SLA’s & Work towards Designated Tasks
• Tracking of customer communication for effective grievance resolution within TAT & SLA’s Compliance- Through knowledge of products, regulations, guidelines is must to ensure process compliance all the time.
• Claim Analytics- Periodical claim analysis to identify frauds, monitor claim performance metrics.
• Informing the customer about the rejection of their claim through call
• Involves identifying discrepancies, fraud, or errors in claims to ensure compliance with health insurance policies and regulatory requirements

What are some of the good to have skills for this role?

• Medical Graduate in any stream (MBBS/BHMS/BAMS/BUMS/BDS)
• Experience in handling audit
• Background in claims processing with clinical experience in a hospital setting
• Data analytics experience would be an added advantage
• Ability to handle independent assignments & having the acumen to take logical conclusions
• Should have a broad understanding of Claims Practice
• Sharp business acumen to understand health insurance claim servicing needs
• Excellent communication skills, including writing reports and presentations
• Ability to anticipate potential problems and take appropriate corrective action
• Knowledge of health regulations, IRDA circulars is a must.
• Knowledge of different languages would be an added advantage. Proficiency in Hindi and English is mandatory.