Girish Kumar

Health Insurance Claims (Operations, Quality Assurance and Training) :

 Handling a Team of claims processors on day to day basis and providing assistance in all reviews related to medical/surgical billings for reasonable and necessary charges, medical coding of operative reports, procedures, and multiple and complicated surgeries.

 Assisting Medical department in providing second review of bills on which providers question the appropriateness of payments authorized.

 Responds to questions, telephone calls, and letters regarding the company's cost containment program, utilization review decisions, and reductions.

 Supervising all processes related to Medical billings in terms of Auditing, evaluation, processing, and validation of claims, with regards to eligibility as per the company's terms and conditions.

 Communicate policy and rules to Reimbursement Claims evaluations team to finalise claims as per terms and conditions.
 Supervising all types of Training and assisting claims staff on ICD-9, ICD 10, CPT coding, quality health care cost containment and utilization reviews.

 Assists and advises claims staff concerning the monitoring of claimants' medical treatments.

 Establishes channels of communication with providers to familiarize them with company guidelines.

Internal Business Process and Team Management:

 Supervising team functions of the entire organisation, viz. manpower planning, interview & selection, induction, performance appraisal, training, etc.

 Mentoring & monitoring the performance of team members to ensure efficiency in process operations and meeting of individual & group targets.

 Creating and sustaining a dynamic environment that fosters development opportunities and motivates high performance amongst Team members.

 Communicate performance data as such would be related to quality/quantity aspects to allow for proper recognition of work evaluations.

 Active involvement in the implementation and continuous improvement of TAT.

 Provide feedback on their output and performance.

 Develop and recommend improvement of facilities, equipment, or procedures to improve safety, quality, and efficiency.

 Monitor usage of utilities to ensure efficiency; establish a culture of continuous improvement in a safe working environment.

Risk Consulting and Internal Audits

 Preparation of the Drafts and Final Internal Audit Reports.
 Preparation of Audit Plans, Audit programs, conducting Risk assessments before execution of audits.
 Preparation and Conducting Gap Assessment reports based on Corporate Governance and carrying out special reviews.
 Conduct Audit work based on established Audit plans and execute the Audit in accordance with established standards ensuring completion within prescribed budget, time and scope parameters.
 Present objective and independent Audit opinion on the adequacy of Internal controls in accordance with established Audit standards, including presentation of findings and recommendations to Audit management.
 Conduct risk assessment of assigned department or functional area in established/required timeline.
 Review the suitability of internal control design. Conduct audit testing of specified area and identify reportable issues and dimension of risk.
 Conducting kick off meetings, exit meetings with the Senior Management of the client.
 Process audits such as Procurement, Marketing, Revenue, Human Resources, Finance, Legal etc.
 Conducting ad-hoc activities such as preparation of Internal Audit proposals, performing Risk Management prior to acceptance of engagement, follow up on invoices on the client and maintaining chargeability.
 Follow-up on audit findings raised by regulatory and divisional Audits.
 Planning Internal audits on Quarterly basis to meet the QMS requirements and ensure that all the process within the organisation follows ISO 9001; 2008 Quality Management Systems as per international guidelines.
 Preparation Corrective and Preventive action plans for Non conformance raised during internal Audits.

Implementing QMS (ISO 9001:2008)

Ensuring Successful Implementation of Quality Management System

 Ensuring that all necessary QMS processes are adequately defined, effectively deployed, and continually kept up.
 Coordinating through one or more project teams who define processes relating to their areas of responsibility and involving appropriate functional managers.
 Assisting MR in providing training for developing the ISO 9001:2008 QMS processes requirements and related documentations to ensure adequate understanding of what is required within the organisation.
 Responsible to ensure that there is effective Document control Function within all the related processes

 Ensuring effective coordination of Internal Auditors to monitor the compliance and effectiveness of QMS
 Planning Internal audits on Quarterly basis to meet the QMS requirements and ensure that all the process within the organisation follows ISO 9001; 2008 Quality Management Systems as per international guidelines
 Preparation and successful execution of Internal Audit Plan as per Internal audit schedule
 Preparation Corrective and Preventive action plans for Non conformance raised during internal Audits
 Distribution of Internal audit reports to all the processes after internal audits and discussion with Functional Managers about the open issues (NCR’s) thorough successful resolution.

Claims Management
 Overseeing insurance claims based on coverage, appraisal, and verifiable damage.
 Reconciling the claims as per the prescribed claim process.
 Effectively following-up with the claim investigators, field staff for speedy and effective claim settlement.
 Ensuring all enquiries/payments are dealt with quickly, keeping the files & documents updated.
 Carrying out interaction with the clients and attending their grievances.
 Experience in Handling ICD 9& ICD 10 coding cases along with conversions of diseases into ICD codes.
Process Management
 Mapping business requirements and coordinating in developing and implementing processes.
 Analysing the data and providing the information that helps in overall growth of the organisation.
 Removing unnecessary procedures in processes; ensuring uniformity in the process understanding at the client’s and the organization’s end.
 Monitoring the overall functioning of processes, identifying improvement areas and implementing adequate measures to maximize customer satisfaction level.

Team Management
 Supervising team functions of the entire organisation, viz. manpower planning, interview & selection, induction, performance appraisal, training, etc.
 Mentoring & monitoring the performance of team members to ensure efficiency in process operations and meeting of individual & group targets.
 Creating and sustaining a dynamic environment that fosters development opportunities and motivates high performance amongst Team members.