Medical Evaluation Specialist

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

Job summary

Plum is seeking a Medical Evaluation Specialist to review health insurance claim decisions with medical rigor, ensuring accuracy, adherence to medical protocols, and fair assessment of medical conditions. You will analyze claim documents, collaborate with treating doctors, and prepare dispute reports while maintaining confidentiality and adhering to Indian insurance regulations.

This role requires MBBS/BAMS/BHMS and 5+ years of clinical/claims adjudication experience, with strong data analysis

Qualifications

• Requires MBBS/BAMS/BHMS with minimum 5 years of clinical/claims adjudication experience.
• Strong analytical and critical thinking abilities essential.
• Excellent written and verbal communication skills required.

Responsibilities

• Conduct comprehensive reviews of health insurance claim decisions against medical protocols.
• Build case files with medical rationale and proofs for reconsideration by insurers/TPAs.
• Analyze medical documentation to establish claim validity and identify errors.

Skills

Analytical thinking

Critical thinking

Written & verbal communication

Independent + team collaboration

Education

MBBS

BAMS

BHMS

Tools

Digital claim review platforms

Medical documentation review

Job description

Plum is an employee insurance and health benefits platform focused on making health insurance simple, accessible and inclusive for modern organizations.

Healthcare in India is seeing a phenomenal shift with inflation in healthcare costs 3x that of general inflation. A majority of Indians are unable to afford health insurance on their own; and so as many as 600mn Indians will likely have to depend on employer-sponsored insurance.

Plum is on a mission to provide the highest quality insurance and healthcare to 10 million lives by FY2030, through companies that care. Plum is backed by Tiger Global and Peak XV Partners.

About the role

We are seeking qualified medical professionals to join our team as Medical Evaluation Specialist. The ideal candidate will leverage their medical expertise to critically review health insurance claim decisions, ensuring accuracy, adherence to medical protocols, and fair assessment of medical conditions. This role plays a vital part in safeguarding the integrity of medical claims, ensuring that patient care and appropriate medical practices are at the forefront of decision-making.

Role Responsibilities

• Comprehensive Claim Reviews: Conduct thorough evaluations of health insurance claim decisions, ensuring compliance with medical protocols and standards for the rejected claims
• Decision correction: Take up rejected claims post review with Insurance companies or Third Party Administrator (TPA) doctors/adjudicators for reconsideration/corrections by building a case file with medical rationale/ medical protocols, proofs from treating doctors etc.
• Documentation Analysis: Analyze claim medical documentation in detail against policy terms and conditions to establish the validity of claims.
• Error Identification: Identify and document potential assessment errors, procedural gaps, and misinterpretations of medical evidence that may affect claim outcomes.
• Dispute Reporting: Prepare detailed and well-structured dispute reports for claims that do not conform to appropriate medical assessment standards, articulating the rationale and evidence base.
• Collaboration: Work closely with insurance teams to provide medical insights and recommendations aimed at improving claim processes and outcomes.
• Confidentiality: Maintain strict confidentiality regarding patient and claim-related information, adhering to all privacy regulations.
• Regulatory Compliance: Ensure all processes comply with Indian medical insurance regulations and guidelines, staying updated on the latest changes.
• Report Preparation: Create clear, concise, and professionally formatted review reports for internal and external stakeholders.
• Interacting with treating doctors for case discussions as per requirement
• Continuous Training: Participate in ongoing training and development opportunities to remain informed on medical insurance protocols and best practices.

Role Requirements

Education and Professional Qualifications

• Required Educational Background: A mandatory degree in one of the following with a minimum of 5 years of clinical/claims adjudication(insurance) experience or both:
• MBBS (Bachelor of Medicine, Bachelor of Surgery)
• BAMS or BHMS
• Strong understanding of medical terminology and clinical procedures.
• Exceptional analytical and critical thinking abilities.
• Excellent written and verbal communication skills.
• Proficiency in medical documentation and record review processes.
• High attention to detail and accuracy.
• Ability to work independently while also collaborating effectively within a team.
• Familiarity with the Indian healthcare system and insurance practices.

Preferred work experience

• Experience between 5 to 10 years of clinical/claims adjudication (insurance) experience or both:
• Understanding of health insurance policies and claim assessment processes.
• Experience with digital documentation and review systems.
• Additional certifications related to medical insurance or healthcare administration are a plus.

Technical Requirements

• Strong data analysis capabilities.
• Comfortable using digital claim review platforms and tools.