Onsurity
Website:
onsurity.com
Job details:
JD :
Role Summary
We are looking for experienced doctors who will independently review, assess and decide health insurance claims (cashless & reimbursement) for the Onsurity portfolio, ensuring fair, fast and accurate claim decisions while protecting both member interests and insurer loss ratios.
Key Responsibilities
- Medical Adjudication & Decisioning
- Evaluate cashless and reimbursement claims (IPD, day-care, high-value cases, complex cases) in line with policy terms, clinical protocols and regulatory guidelines.
- Interpret diagnosis, investigations, treatment plans and line of management to determine whether the claim is medically and contractually admissible.
- Recommend approvals, partial approvals, denials or further queries with clear, well-documented medical reasoning.
- Pre-auth & Discharge Management
- Review hospital pre-auth requests and provide decisions within agreed TATs.
- Handle enhancement requests, discharge approvals and billing disputes in collaboration with TPA’s network and hospital teams.
- Quality, Compliance & Documentation
- Ensure compliance with insurer/TPA SOPs, IRDAI guidelines and Onsurity’s internal standards.
- Maintain high-quality documentation for every decision, enabling easy audit/tracing.
- Support periodic internal audits and TPA audits with medical justifications as required.
- Fraud Control & Cost Optimisation
- Identify suspicious / potentially fraudulent claims based on medical red flags, patterns and hospital behaviour.
- Recommend investigations, second opinions and enhanced scrutiny where needed.
- Work closely with the claims leadership to support cost control, negotiation and FDE initiatives without compromising genuine member care.
- Stakeholder Collaboration
- Work closely with Onsurity operations, customer support, insurer medical teams, and Vidal teams to resolve complex cases.
- Provide medical clarifications for internal teams and support in drafting member communications where required.
- Participate in case discussions, tri-party reviews and training sessions to continuously improve quality and consistency.
- Process Improvement & Training
- Suggest process improvements, rule refinements and clinical protocols based on recurring patterns.
- Mentor junior medical/claims staff (over time) and contribute to building a strong medical governance culture within Good Doctors.
Desired Profile
- MBBS/BAMS/BHMS or any medical degree from a recognised authority (in Internal Medicine, General Medicine, Family Medicine, Emergency Medicine or related specialities will be an advantage)
- 5–10 years of total experience with at least 5+ years in health insurance/TPA claims adjudication (cashless and/or reimbursement).
- Solid understanding of:
- Health insurance products & policy wording
- IPD, day-care, surgical procedures, high-cost therapies
- Medical necessity, reasonability, and standard treatment guidelines
- Comfortable working in a high-volume, fast TAT environment with strong attention to detail and documentation.
- Good written and verbal communication skills in English (knowledge of Kannada/Hindi is a plus).
- Strong sense of ethics, fairness and customer centricity – able to balance member empathy with prudent risk management.
Click on Apply to know more.