Case Management & Medical Audit - Bangalore

Medi Assist; Bengaluru; On-site; INR 1,200,000 - 1,800,000; Full time

Job summary

Medi Assist leads the Lead Case Management & Medical Audit initiative in Bangalore to drive clinical audit processes, review high‑value or complex claims, and negotiate real time and post‑facto price settlements with provider hospitals for optimized claims spend.

The role requires 4–8 years’ experience in clinical audit, medical case management, or TPA claims audit, with MBBS/BAMS/BHMS or MHA/MPH qualifications. Strong negotiation and medical‑legal literacy are essential for success.

Qualifications

• Medical degree or Masters in Hospital Administration (MHA) / Public Health (MPH).
• Hands-on experience in medical auditing, utilization review, or claims management in an insurance/TPA environment.
• High medical-legal literacy and strong financial negotiation capability.

Responsibilities

• Drive clinical audit processes and review high‑value or complex claims.
• Lead real-time and post‑facto price negotiations with provider hospitals to optimize claims spending.
• Establish audit guidelines, medical necessity protocols, and tariff adherence frameworks.
• Collaborate with insurer's claims processing team to share findings, fraud trends, and cost‑containment insights.

Skills

Medical auditing

Utilization review

Claims management

Financial negotiation

Education

MBBS/BAMS/BHMS

MHA/MPH

Job description

Job Description : Lead Case Management & Medical Audit

• Location: Bangalore
• Experience: 4–8 Years (Clinical Audit, Medical Case Management, TPA Claims Audit)
• Role Summary: Drive clinical audit processes, review high-value or complex claims, and lead real-time and post-facto price negotiations with provider hospitals to optimize claims spending for partner insurers.
• Key Responsibilities:
• Perform clinical and financial audits on targeted hospital claims to identify billing discrepancies, unbundling, or tariff non-compliance.
• Negotiate directly with hospital management for discounts on high-cost cases, non-tariff procedures, and length-of-stay (LOS) optimizations.
• Establish audit guidelines, medical necessity protocols, and tariff adherence frameworks.
• Collaborate with the insurer's claims processing team to share findings, fraud trends, and cost-containment insights.
• Qualifications & Skills:
• Medical degree (MBBS, BAMS, BHMS) or Master’s in Hospital Administration (MHA) / Public Health (MPH).
• Hands-on experience in medical auditing, utilization review, or claims management in an insurance/TPA environment.
• High medical-legal literacy and strong financial negotiation capability.

Thanks & Regards

Hariprasad