Key Responsibilities/ What you do:
•Responsible for the clinical assessment of medical claims to ensure compliance with medical necessity, policy coverage, and clinical guidelines.
• Review inpatient and outpatient medical claims for clinical accuracy
• Validate diagnoses, procedures, and services against medical records and policy terms
• Identify discrepancies, overutilization, or non-compliance with guidelines
• Collaborate with claims teams to support adjudication decisions
• Ensure decisions are in line with medical policies and regulatory requirements
• Other Ad hoc duties as required
Key Requirements/ What you bring:
• MedicalParamedical Degree (MBBS, MD, BS Pharma, PharmaD, BDS, BDent, or equivalent)
• Minimum 1–3 years of clinical practice or medical review experience
• Familiarity with ICD, CPT, DRG coding, and insurance guidelines
• Strong a...