Health Claims Audit, AYUSH/MBBS)

About the Role

This is a full-time, on-site Health Claims Audit role based in Hyderabad, focused on claims related to Retail and Corporate Health Insurance Policies.

Key Responsibilities

• Review and audit health insurance claims for clinical accuracy, policy compliance, and adherence to internal guidelines.
• Examine medical records, prescriptions, diagnostic reports, and treatment plans to validate medical necessity and identify potential discrepancies or fraud.
• Collaborate with claims processors, underwriting, finance teams, and external medical providers to clarify medical details and resolve claim queries.
• Contribute to improving audit processes, documenting findings, and preparing reports.
• Support training initiatives to enhance claim quality and compliance.

Requirements & Tech Stack

• Analytical Skills for reviewing medical records, identifying inconsistencies, and assessing claim validity.
• Communication skills to interact with internal teams, healthcare providers, and stakeholders.
• Knowledge of Finance and the ability to interpret Financial Statements to understand claim cost implications and billing practices.
• Auditing skills, including familiarity with audit methodologies and compliance frameworks for health insurance claims.
• Ability to work with claim management systems and basic proficiency in MS Office (Excel, Word, PowerPoint).
• Strong attention to detail, integrity in handling sensitive data, and the ability to work in a fast-paced, team-oriented environment.

Qualifications

• Recognized medical qualification such as MBBS or AYUSH (BAMS, BHMS, BUMS, BNYS, or equivalent) from an accredited institution.
• Experience in health insurance, hospital billing, medical underwriting, or claims assessment/audit is preferred.
• Understanding of clinical protocols, standard treatment guidelines, and regulatory requirements in the healthcare and insurance sectors.