Job Title

JD :Role SummaryWe 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 ResponsibilitiesMedical Adjudication & DecisioningEvaluate 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 ManagementReview 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 & DocumentationEnsure 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 OptimisationIdentify 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 CollaborationWork 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 & TrainingSuggest 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 ProfileMBBS/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 wordingIPD, day-care, surgical procedures, high-cost therapiesMedical necessity, reasonability, and standard treatment guidelinesComfortable 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.