Senior 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 Navi’s 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.
• Identify any inconsistencies, overbilling, or discrepancies between services provided and the claims submitted
• Detect potential fraudulent claims by analyzing patterns and identifying suspicious activities or behaviors
• Providing detailed reports on audit findings, Decision accuracy, including identifying overpayments, underpayments, or fraudulent activities
• Recommend actions based on findings, such as denying, reducing, or adjusting claims
• Communicate audit results and findings to management and external stakeholders
• Suggest process improvements to enhance the efficiency and accuracy of the claims audit process.
• Stay updated with industry trends, regulations, and changes in healthcare policies that may impact claims auditing
• Provide guidance and training to claims team members or other related stakeholders
• Investigating medical claims to identify fraud
• Automate system and bring in improvements on claims processes
• Team Management- Build and manage the team of doctors supporting the function
• The role 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
• Knowledge of different languages would be an added advantage. Proficiency in Hindi and English is mandatory.
• Knowledge of health insurance policies and regulations, IRDAI circulars is must
• Strong analytical and problem-solving skills.
• Excellent attention to detail and ability to spot discrepancies
• Ability to anticipate potential problems and take appropriate corrective action
• Effective communication skills for working with different stakeholders
• Time management skills to meet deadlines.
• 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