Medical Analytics & Audit Officer

JD - SOG Medical Analyst:

Analysis:

• Identification of cases for analysis from data dump and further analysis as per the requirement and arrive at the root cause and possible solution for the same.

Presentation/Reporting:

• To provide a timely and detailed report on the analysis done

Data management:

• Maintaining the data for all the analysis done with respect to data duration ,numbers analysed etc.

Medical knowledge:

• To have a fair medical knowledge in order to identify the possible reasons for overriding

Communication:

• To be able to communicate and present the analysis.
• The candidate should have good excel knowledge.
• Also, the candidate should have previous minimum 4-5 years of experience in insurance sector.
• Background should be a doctor.

For Audit:

JOB DESRCIPTION:

The role involves auditing claims and preauthorization, to ensure clinical appropriateness, policy compliance, and correct system processing. It requires a strong blend of medical understanding and system knowledge to identify errors, investigate their root causes, and support in improvement of workflows.

Key Responsibilities

Medical and System-Based Auditing

1.Review claims and pre-auths processed to ensure accuracy in clinical decision-making and alignment with policy guidelines.

2.Audit system-generated outcomes to verify that automation logic supports correct and compliant decisions.

3.Identify deviations, mismatches, or logic failures that impact outcomes.

Root Cause Analysis and Error Investigation

1. Analyze audit findings to determine whether issues stem from clinical misjudgment, system configuration, or data input errors.

2.Document root causes clearly and escalate cases where system logic correction or process improvement is needed.

3. Monitor recurring issues and contribute to preventive solutions.

System Logic Review and Enhancement Support

1.Understand rules engines, logic flows, and automation triggers used in claims and preauth systems.

2.Validate logic changes before implementation by reviewing test cases and outcomes.

3.Provide feedback to improve system accuracy and minimize manual overrides.

Collaboration and Communication

1.Work closely with internal teams including medical, product, IT, and claims to align on audit findings and corrective actions.

2.Share insights and support knowledge transfer based on audit observations.

Documentation and Reporting

1.Maintain structured records of audit findings, types of errors, financial or process impact, and resolution steps.

Role & responsibilities

Preferred candidate profile