Requirements
Requires a Bachelor's degree in medicine (MBBS) or equivalent healthcare qualification, preferably a Physician, Dentist, or Pharmacist. Minimum 2-3 years of experience in clinical practice, medical claims management, medical review, health insurance, or revenue cycle operations is essential. Proficiency in data reporting (Excel, PPT, Power BI) and Electronic Medical Records (EMR) is required, along with strong English communication and problem-solving skills.
Description
Purpose of Job:The Medical Validator is responsible for reviewing and validating all medical records, clinical documentation, and claim-related information to ensure accuracy, completeness, consistency, and medical appropriateness prior to claim submission. The role serves as a critical quality gate between clinical operations and Revenue Cycle Management (RCM), ensuring that all medical reports and claims are medically justified, quantitatively accurate, qualitatively complete, and compliant with requirements before being handed over to the RCM team for submission and collection.Duties and Responsibilities:Review and validate inpatient, outpatient, emergency, and day-case medical records to ensure completeness and accuracy of clinical documentation.Verify that diagnoses, procedures, investigations, medications, and treatment plans are adequately documented in the medical record and justified by the medical necessity.Assess and validate the medical necessity and appropriateness of services rendered in accordance with accepted clinical practice and requirements.Review claims and medical documentation prior to submission to ensure medical accuracy, consistency, and readiness for reimbursement.Validate the qualitative aspects of medical records, including documentation completeness, clinical justification, physician notes, operative reports, discharge summaries, and supporting reports.Validate the quantitative aspects of claims, including diagnoses, procedures, length of stay, utilization of services, consumables, investigations, and billed items against the documented medical record.Intervene in cases of suspected Fraud, Waste, and Abuse (FWA), collaborating closely with physicians, medical teams, and healthcare practitioners to execute corrective actions that minimize financial loss while prioritizing patient safety and quality of care.Ensure alignment between clinical documentation and claim data prior to submission.Identify missing, incomplete, or unsupported clinical information that may affect claim approval or reimbursement and coordinate timely resolution with the relevant clinical teams.Support denial prevention by identifying documentation and medical necessity gaps before claiming submission.Collaborate closely with physicians, nursing teams, medical records staff, coding teams, billing and the Revenue Cycle Management department to improve claim quality and submission accuracy.Provide medical clarification and validation support for claim-related inquiries and documentation requirements.Job Requirements:Education:Bachelor's degree in medicine (MBBS) or equivalent healthcare qualification. Preferably a Physician, could be Dentist or Pharmacist.Certifications:Certifications in healthcare quality, medical coding, health insurance, or revenue cycle management are advantageous.Experience:Minimum 2–3 years of experience in clinical practice, medical claims management, medical review, health insurance, or revenue cycle operations.Experience in both medical documentation review and claims handling is highly preferred.Technical Skills and Knowledge:Proficiency in data reporting and analytics using Excel, PPT, and Power BI.Proficiency in Electronic Medical Records (EMR) and healthcare information systems.Desirable experience with ICD coding principles, and healthcare insurance practices.Soft Skills: Excellent command of English, strong communication and stakeholder management skills, problem solving, and the ability to take initiative while working effectively within a team.