Medical Reviewer

Role Overview

Your Role

• Evaluate healthcare needs by reviewing medical records, insurance policies, and treatment plans in collaboration with providers and clients.
• Assess members’ risk exposure in line with medical underwriting policies.
• Evaluate cases to support member satisfaction, meet turnaround times, and manage costs through prescribed measures such as DRG debates.
• Manage provider, insurance company, and insured-member queries relating to approvals accurately and promptly.
• Provide medical guidance to Claims Department staff and assist with accurate coding and Add-on/LTC reviews.
• Deliver customer service to insurance companies and insured members.
• Manage cases and attend hospital visits to investigate claims and minimize fraud and abuse.
• Compile data and prepare monthly statistical reports to monitor departmental performance and medical trends.

Your Profile

• Medical degree (MBBS or equivalent) from a school recognized by the WHO.
• 2–3 years of experience in Medical Claims Evaluation, In-Patient Approvals, or Case Management, preferably in a TPA or MSO organization in the insurance sector.
• Certified Medical Coder (CPT/ICD/DRGs) with relevant experience in DRG debates and severity negotiations.
• Industry knowledge of the local healthcare services system.

About the Employer