Claims Manager
eCare International
Total years of experience :17 years, 3 Months
Managing and controlling IP & OP approval process and claims
accordingly
Analyzing provider treatment pattern and fraud and abuse analysis
Liaise with Company Operations, Legal & other internal departments,
Insurance Companies and Providers to facilitate claim management and
effective solutions
Liaise with related third parties to facilitate home country treatments
• Accountable for:
o Developing, updating and implementing policies and procedures as per functional objectives of business
o Investigating, negotiating and settling claims within delegated authority
o Approving all OP & IP cases as per medical requirements and TOB
o Auditing claims against eligibility as per Table of Benefits & medical necessities and ensuring the authorised services are as per network
o Ensuring accomplishment of response time for each approval and claim
o Controlling & investigating fraud and abuse of the Health Insurance Policy; ensuring highest quality of service
• Working in coordination with providers to meet the standard criteria led by DHA for online approvals and claims
• Providing support to providers for issues related to e-claim link, online approvals, payments and other grievances
• Prepare & analysing statistics including Claim Ratio and Average Claim Ratio
• Driving the team to achieve monthly team targets of claims processed; arranging training programs for the team to help them achieve the highest level of quality in processing of daily claims
Brands Handled:
• Allife (Ginseng preparation)
• Fexonorm (Fexofenadine)
• Grobcide (Cefixime)
• Acelomol (Aceclofenac + Paracetamol)
Accomplishments:
• Developed Marketing and Operations Teams from scratch
• Played a pivotal role in introduction of new products and in development of new territories & markets
• Contributed extensively to budgeting, planning and forecasting
Handling the Manav care division with a portfolio of INR 25 crores.
Planning and assuring implementation of the brand strategies.
Preparing promotional inputs for the field .
Budgeting and ensuring achievement of topline and bottom line.
Training to the filed force and training and development of the product executives
Sales forecasting, Sales Projection, Training and Motivating Field force, Designing Visual Aids, Planning and Implementing promotional srategies