Claims Retrospective Officer

Responsibilities

• 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.

Qualifications

• Medical/Paramedical 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 analytical and decision-making skills.