Claims Medical Officer

About the role

The Claims Medical Officer works within the Claims Department to evaluate medical evidence and ensure fair, accurate claim payments in line with company SOPs and policy terms. This role bridges medical expertise with insurance operations, supporting timely decisions for cashless authorisations and dispute resolution.

Key responsibilities

• Assess hospital records, laboratory results, pathology reports, specialist opinions and other clinical documentation to determine claim eligibility.
• Maintain consistency, accuracy and objectivity in medical claim adjudication.
• Present medical opinions and recommendations to Heads of Department for final decision‑making.
• Interpret medical terminology, disease progression and treatment protocols to support business decisions.
• Liaise with hospitals, healthcare providers and TPAs on cashless authorisation requests.
• Detect inconsistencies, fabricated documents or fraud indicators and recommend investigative actions.
• Analyse claims data, prepare reports and identify emerging medical risks and process‑improvement opportunities.

Required profile

• Medical degree (M.B., B.S.) preferred.
• 3–5 years experience in healthcare administration or a clinical setting.
• Strong analytical ability to review complex medical records and make fair decisions.
• Excellent written and verbal communication in English and Myanmar.
• High ethical standards, impartiality and discretion with sensitive data.
• Ability to make decisive judgments under pressure and resolve disputed claims.

Required skills