Hospital Network Partnership, Specialist

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About the Role

To serve as the key liaison between AIA/AHS and panel hospitals, ensuring effective relationship management, cost containment, claims coordination, and operational excellence. The Medical Officer will play a critical role in building relationships with specialist doctors in hospitals, ensuring the delivery of the right services at the right time and cost. Additionally, the Medical Officer will enhance service quality, detect fraud, and support digital transformation initiatives within hospital settings.

Roles and Responsibilities:

1. Relationship Management

• Build and maintain strong, professional relationships with hospital management, doctors, and medical staff.

• Act as the primary liaison between AIA/AHS and panel hospitals to address concerns, resolve disputes, and ensure smooth collaboration.

• Conduct regular engagement sessions with hospital administrators to review service quality, cost efficiency, and process improvements.

• Engage with specialist consultants in private hospitals to foster collaboration and alignment with AIA's clinical direction and strategic goals.

• Encourage and support specialist doctors in working with AIA by building trust, understanding their needs, and aligning mutual objectives.

2. Cost Management

• Monitor treatment costs and billing practices to ensure alignment with AIA/AHS cost containment strategies.

• Collaborate with the claims team to verify medical necessity and prevent overcharging.

• Educate hospital staff on AIA/AHS policies, clinical guidelines, and preferred treatment pathways.

3. Fraud Detection & Risk Management

• Identify and report suspicious billing patterns or potential fraud cases.

• Conduct audits on high value claims to detect anomalies and ensure compliance with internal standards.

• Work closely with the AHS fraud investigation team to mitigate risks and uphold integrity.

4. Claims Handling

• Support the fast-tracking of urgent and high-priority claims.

• Mediate and resolve claim disputes between hospitals and AIA efficiently.

• Guide policyholders on claims procedures, eligibility, and documentation to enhance customer experience.

5. Operational Efficiency & Process Improvement

• Provide feedback to internal teams on hospital operational challenges and suggest actionable improvements.

• Collaborate with the network management team to optimize panel hospital performance and selection.
• Support digital initiatives such as e-claims processing and cashless payment systems.

Minimum Job Requirements:

Qualifications & Experience:

• Medical degree (MBBS or equivalent) with full registration.
• Minimum 3 years of clinical experience, preferably in private hospital settings.
• Strong interpersonal and communication skills must be confident and outspoken.
• Proven ability to build rapport with hospital stakeholders and work collaboratively.
• Analytical mindset with attention to detail in claims and billing practices.
• Strong problem-solving skills with a proactive and solution-oriented mindset.
• Ability to work independently while collaborating with internal teams.
• Familiarity with insurance/TPA operations is an added advantage.
• Willingness to be based at or travel frequently to assigned hospitals.