SENIOR INSURANCE MANAGER/SUPERVISOR
AL AHLI HOSPITAL
Total years of experience :16 years, 11 Months
• A dynamic professional with over 9 years of experience in Health Insurance Claims Management, Provider management, MIS, SLA Management and cost control .
• Deft in identifying fraudulent claims and claims cycle.
• Adept in managing & leading teams for running successful process operations
• An effective communicator with excellent relationship building & interpersonal skills
• Management of rejection claims and reconciliation with the Insurance companies.
• Effectively and efficiently handling the team of Processors for error free Processing within TAT (turnaround time).
• Ensure to reduce the billing wastes i.e. Timely collection and submission of Claims to the insurance companies.
• Instrumental in controlling the Rejection Ratio.
• Involved in giving Presentation to Paramedical staffs as well as Doctors to explain the insurance exclusions and inclusions.
• Manage the contract management system process, which ensures:
-All existing contracts are scanned and loaded in the system.
-New Insurance company’s agreements are processed through the system.
• Administered a team of specific members; deftly conducted weekly team meetings along with Supervisors & Team Leaders.
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• Diligently reported on daily & weekly basis observations and non-performances with suggestions for improvement
• To Maintain a Close Coordination with Clients, corporates and Insurance Companies.
• Handling issues related with guest service.
The organization is a operating in the field of insurance consultancy to businesses, risk management, TPA services for Health Insurance
Responsibilities / Achievements
In Pre-approval Department & Networking:
• Approval/decline of pre authorization of cashless service.
• Working in close coordination with AXA PPP (Our reinsurance partner)
To get PPP approvals for the high value claims.
• Empanelment of various Hospitals.
• Fraud control and Investigation.
• Cost Negotiation with the provider to get best possible deal.
• Carried out the maintenance of hospital price & package charges & negotiated on periodic basis.
• Voluntarily visited to the hospitals and clinics for detecting fraud.
• Establish and maintaining records on Provider pricing Grading.
• Initiate customer feedback exercises and provide feedback to the management.
• Handling 24 hours helpline Mobile phone for queries, disputes
Related with Medical insurance from client corporate Providers.
• Giving Pre approvals to Claim Deviation cases (treatment abroad).
In Claims Department:
• To Work in Building International standards in claims department i.e. Medical claims processing.
• Steered efforts in reducing turnaround time in claims processing
• Medical Auditing of Hospital as well as reimbursement Claims strictly in accordance with the guidelines laid by AXA PPP, CCHI (council for cooperative health insurance)
• Getting approvals for the claim deviation cases (Treatment outside area of cover) from healthcare manager.
• Undertook necessary corrective and preventive action to ensure that there was no deviation from the processes and guidelines laid were down in various operations manuals
• Administered a team of specific members; deftly conducted weekly team
Meetings along with Supervisors & Team Leaders.
• Conduct performance appraisal of employees down the line.
• Attending monthly meetings with CEO along with staff of higher management. Also sending weekly MIS to the Management.
• Conducting Training programmes to the staff on different subject matters.
Operations: Cashless processing, claims processing, Hospital empanelment, Claims investigations / verifications etc.
• To carry out presentations at Insurance Companies Regional Offices, Corporate to explain them the TPA workings.
• Extensively worked with helpdesk to ensure timely and decisive approvals
• Contracting with Healthcare Providers of different categories ranging from Tertiary care Hospitals, Nursing Homes, Individual consultants, Support System Providers such as Ambulance and Blood Banks etc.
• Involved in giving presentation to our various prestigious clients (ICICI Lombard, Cholamandalam, Reliance group, BTVL, HLL, HUTCH, TATA TELE, PEPSICO, etc).
• Visiting the Hospitals and handling queries related to Admission, denial, Payments etc.