Manager
Total years of experience :17 years, 6 Months
Banking & Insurance ~ Claims Recovery ~ Client Relations
~ Team Management ~ Negotiation ~ Process Management
~ Liaison & Coordination ~ Payment Settlement ~ Strategic Planning
•Curently associated with Star Health & Allied Insurance Co. Ltd., Chennai as
HANDLING RETAIL CLAIMS, TAILOR MADE CLAIMS AND PERSONAL ACCIDENT CLAIMS, CASHLESS AND REIMBURSEMENT PROCESS, FINANCIAL APPROVAL WITH NO LIMIT, TEAM HANDLING, STRATEGIC PLANNING, TAT MAINTAIN, INTERACTION WITH DOCTORS, COORDINATION/MEETING WITH ZONES/BRANCHES, JOB ALLOCATION, SUPERVISE, TEAM PRODUCTIVITY AND ACTIVITY MAINTENANCE, COMMUNICATIONS, TRAINING, TEAM MOTIVATION, TEAM HEAD, TEAM PLAYER, AUDITING, HOSPITAL RELATIONSHIP, HOSPITAL EMPANELMENT, CUSTOMER GRIVANCE, PAYMENT PROCESS, MANAGING THE CONSUMER FORUM CASES, MIS, EXCEL AND MS OFFICE, TEAM ROASTER MAINTAINING, FLOOR ADMINISTRATION
Claims adjudication, Decision on claims settlement/Rejection by verifying the policy conditions, terms and conditions, the coverage of the Insured, diagnosis, duration of the diagnosis, previous Insurance details(Sum Insured change, portability), treatment, sub limits, Co-pay, arranging for theinvestigations to verify the genuinely, if needed, , analysing whether any PED/ Nondisclosure, Seeking documents from the insured by raising queries, recommending for Endorsing/Cancellation on specific disease.
Title: Group Medical-claim (GMC Claims
Insurance coverage to the Govt. employees of Tamil Nadu
Key Result Areas:
•In-charge of the claims Team including Cashless, Accounts, Customer Care and Administration and also financial approver
•Ensured that the Pre-authorisation request comes from the hospitals are processed and the communication sent to the hospital
•Attended the Walk-in clients and replying them the status of the claims/doubts and pacifying the clients suitably
•Tough claims will be discussed with the Medical Team and the General Manager and finding the proper complete solution without Customer compromise
•Administrative decisions on claims
•Liaison with the hospitals regarding the claims like Negotiation on claims, outstanding claims
•Empanelment of the hospitals
•Visited the hospitals regarding the hospital infrastructure verification, empanelment and package rates negotiation
•Successfully reduced the claims ratio by implementing the negotiation with the hospitals on specific rates
•Monitored the Accounts and the administration activities
•Managed the customer care department
•Ensured that the all the calls are attended and answered properly
•Attended the escalation calls and providing solutions
•Allocated to the Shifts and roasters and ensure that round the clock the customer care team functions without deficiency/man power shortage
•Assisted with IT software department with my insurance domain knowledge in creating a complete tool for the project
•Adjudication of claims: Verification of the claims and final Approval for the financial part
Ensuring that the claim files submitted are given top priority, processed within three days of receipt of the claims to the at most satisfaction of the Client and Marketing Team.
Key Result Areas:
•Ensured that the claim files submitted by the companies at various offices in India are reached properly to the Head Office
•As a In charge of the Group Medical Claims (GMC), worked as Single point of contact to the branch offices/companies like communicating the companies and office regarding the status of the claims
•Explaining them the reasons for the rejections and deductions in the claims submitted
•Periodical meeting with the Zonal/ Branch offices regarding the claims ratio
•Special watch on the high claims prone companies and by analysing the reasons and advising stop loss opinion to the management.
•Assisted the Sales team by keeping the high importance on claims processing without delay and ensure the customers satisfaction on the claims services
Title: Rajiv Aarogya Shri Health Insurance Scheme
The Aarogya Shree health Insurance Scheme - Insurance coverage to the below poverty Line people at Andhra Pradesh
Key Result Areas:
•Team Lead to the Claim settlement team contains 9 Members and reported to General Manager and Claims
•Ensuredthat the Claims documents received from the hospitals are in warded properly
•On receipt of the Claim Documents Ensure that the claims are processed by the Medical Team, then ensure that the claims files are sent to the accounts department for the settlement/payment without fail
•Communicated with the hospital regarding the claims status to the hospitals Query letters, in case of any additional documents/clarification required to process the claims
•Updated all the claims information like (inward, status of the claims, settlement, payment effected) and maintain the data in the excel sheet
•Used Excel Generated the daily reports and various types of Claims MIS are done and sent periodically to the Government and the Entire claims data has been managed through Ms Excel
Title: Tamil Nadu Govt. Employs New Health Insurance Scheme
Claim Operations)
Key Result Areas:
•Determining least financial strain on company, and providing quality service to internal customers
•Settling the claims, based on the documents and reports for final settlement and data analysis
•Controlling customer grievancesby conducting out of court settlement by negotiation
•Interacting with medical team and ensuring that the claims are processed timely
•Ensuring that the claim files submitted by the customers at all locations of the zone are sent to claims department for claims processing
•Chalking out sales strategies to enhance (life or health) insurance and channel partner’s business; designing & rolling out new sales models/ channels andnew product design & launch
•Confirming that all the claims are processed within the TAT
•Synchronising with claims department, Chennai for speedy process of claim settlements
•Managinglawyer notices and consumer forum cases of the entire zone
•Coordinating with advocates, assigning cases, recording and maintaining data of developments of cases, out of court settlement and so on
•Allocating of the claims investigations to the private investigators and obtaining reports &evidences to submit final report to claims department
•Interacting with branches, branch managers and field visit coordinators regarding claim issues
Highlights:
•Nominated and awarded as Outstanding Performer by the Executive Director in 2012
•Bridged the gap between insurers and customers through greater transparency and open house awareness programs
•Designed & ensured successful implementation of processes, policies & system for service delivery
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