Assistant Manager- Claims Doctor

Description

EFU Life Assurance Ltd. seeks a dedicated Assistant Manager- Claims Doctor to join their healthcare claims adjudication team. The candidate must hold an MBBS degree and possess at least two years of relevant experience in medical claims adjudication and clinical record review. This role demands a thorough understanding of medical conditions, diagnoses, treatments, surgeries, and hospital procedures. The Assistant Manager will be responsible for evaluating medical evidence, identifying inconsistencies, and making informed recommendations on claim decisions to ensure accurate and fair adjudication. The position does not involve direct team management but requires strong coordination skills to work effectively with hospitals, doctors, underwriters, and claims teams. The ideal candidate has the ability to abstract medical records, validate clinical documentation, and apply medical coding standards such as ICD-10 accurately. This role is critical in maintaining high-quality claims processing and contributing to the integrity and operational efficiency of the insurance claims department.

Responsibilities

• Review and adjudicate medical claims with a focus on accuracy and compliance with company policies.
• Analyze clinical records and medical documentation to validate medical necessity and appropriateness of treatments.
• Perform detailed medical record abstraction and clinical documentation validation to support claims decisions.
• Evaluate medical evidence critically to identify inconsistencies or discrepancies within submitted claims.
• Apply ICD-10 and medical coding standards for thorough and precise review of diagnosis and treatment information.
• Collaborate and coordinate with hospitals and attending doctors to clarify medical details and resolve information gaps.
• Work closely with underwriters and claims teams to facilitate efficient claims processing and decision-making.
• Recommend claim approvals, denials, or requests for additional information based on medical assessments.
• Maintain up-to-date knowledge of medical advances, procedures, and coding to support accurate claims evaluation.
• Ensure compliance with regulatory requirements and internal policies during claims review and decision processes.

Experience

2 Years

Apply By

Dec 4, 2026

Required Skills

• Medical Claims Adjudication
• Clinical Record Review
• ICD-10 And Medical Coding Review
• Medical record abstraction and clinical documentation validation
• Medical Documentation Analysis
• Claims Evaluation
• Knowledge of medical conditions and treatments

Nice to Have Skills

• Coordination with healthcare professionals
• Regulatory compliance in insurance claims