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Job Description :Position: Medical Officer (Doctor) - TPA for Insurance and Risk AnalysisLocation: MumbaiJob Type: Full-timeAbout Policybazaar For Business :Policybazaar, the flagship platform of PB Fintech Ltd., is India’s largest online insurance marketplace,acclaimed by Frost & Sullivan. Established in 2008, Policybazaar has revolutionized insurance withunmatched awareness, choice, and transparency. Introducing Policybazaar for Business, a dedicatedservice designed to meet the unique insurance needs of enterprises. Launched in 2021, it offers arobust portfolio of 15+ business insurance products tailored to diverse sectors, scales, and risk profiles.Policybazaar for Business aims to fortify India’s financial ecosystem by ensuring every business isinsured and worry-free. With a track record of serving over 25,000 corporates, Policybazaar forBusiness excels in delivering precise risk analysis and bespoke solutions. From chemicals andinfrastructure to IT, renewable energy, hospitality, and logistics, Policybazaar for Business is yourtrusted partner in safeguarding your enterprise& future.Job Overview:We are seeking a qualified and experienced Medical Officer (Doctor) to join our team at Policybazaarfor Business. This role involves using medical expertise to assist in evaluating insurance claims,conducting risk analysis, and ensuring that the medical aspects of claims are handled in accordancewith industry standards and regulations. The ideal candidate will have a strong background inhealthcare and an understanding of insurance policies and risk management in the medical field.Key Responsibilities:Claims Review and Evaluation:• Review medical claims submitted by policyholders to ensure accuracy and compliance withinsurance policies.• Analyze the medical documentation provided by hospitals, clinics, and other healthcareproviders to determine the legitimacy of claims.• Assess the medical necessity of procedures, treatments, and hospital admissions as per theinsurance policy guidelines.• Provide second opinion or consultation on disputed claims or complex medical cases.Risk Assessment and Management:• Perform risk assessments based on medical data and historical trends to help evaluate andmanage potential risks for both policyholders and insurers.• Analyze patient medical history and treatment plans to identify high-risk cases and potentialfraud.• Collaborate with the underwriting team to provide insights into risk factors and potentialareas of concern in the policyholder pool.Medical Advisory Services:• Provide expert advice and medical guidance to the TPA team, insurance providers, andpolicyholders regarding medical treatment, diagnoses, and claims.• Act as a liaison between healthcare providers and the insurance company to ensure aseamless claims process and accurate policyholder information.Policy Development and Compliance:• Assist in the development of health insurance policy guidelines to ensure they are medicallysound and compliant with regulatory standards.• Stay up-to-date with the latest medical trends, technologies, and regulations to ensurepolicies reflect current medical practices.• Ensure compliance with healthcare laws and insurance industry regulations during theclaims processing and risk evaluation stages.Medical Audits and Reports:• Conduct medical audits to ensure the accuracy of claims and prevent fraud.• Prepare detailed reports regarding the medical aspects of claims, risk assessments, andpolicy compliance for senior management and insurers.Collaboration with Medical Providers:• Communicate with healthcare providers, hospitals, and clinics to clarify medical informationand ensure proper documentation is available for claims processing.• Collaborate with medical professionals in cases of complex treatments or potentialdiscrepancies between claimed and provided medical services.Requirements:Educational Qualifications:• Medical degree (MBBS, MD, or equivalent) from a recognized institution.• Relevant specialization (if any) is a plus (e.g., General Medicine, Surgery, etc.).• Experience:• Minimum of 5 years of experience in the healthcare industry, ideally in a clinical orinsurance-related environment.• Experience with medical claims evaluation, health insurance, or risk management is highlydesirable.• Familiarity with healthcare laws, regulations, and insurance policies is a plus.Skills:• Strong understanding of medical terminology, clinical procedures, and healthcare protocols.• Ability to assess medical documents, interpret medical records, and determine thelegitimacy of medical claims.• Analytical skills for risk assessment and decision-making.• Good communication skills to explain medical matters to non-medical professionals (e.g.,insurance teams).• Ability to handle sensitive information and ensure confidentiality.Other Requirements:• Strong attention to detail and accuracy.