Assistant Manager - Aditya Birla Health Insurance Company - Thane, India
(2024-03)
Currently handling the Pune region for field investigations; previously handled the Mumbai region for assigned investigation cases to empanelled vendors based on location, case complexity and TAT.
- Coordinated with investigation vendors for timely case allocation, follow-ups and report submission
- Conducted field investigations for suspicious cashless and reimbursement claims
- Collected patient statements, hospital records and supporting evidence to verify claim genuineness
- Coordinated with hospitals, investigation vendors and internal stakeholders for case follow-up
- Identified fraud indicators such as non-disclosure, misrepresentation, inflated billing and unnecessary hospitalization
- Prepared detailed investigation reports with findings and recommendations
- Supported claim approval, rejection, recovery and hospital blacklisting recommendations
- Maintained investigation quality, timely report submission and strong QC compliance
- Supported decision-making for claim rejection, approval, or escalation
- Previously Handled end-to-end reimbursement claim processing as per policy terms and conditions
- Scrutinized medical records, bills, discharge summaries and investigation documents
- Verified hospitalization details, medical necessity and policy coverage
- Identified non-payable items, discrepancies and documentation deficiencies
- Coordinated with hospitals, insured members and internal teams for claim settlement
- Ensured timely claim settlement within TAT while maintaining high quality standards
- Supported claim decisions including approval, deduction and repudiation
- Assisted the underwriting team in proposal assessment and risk evaluation
- Reviewed medical records, health declarations and supporting documents
- Coordinated with medical and underwriting teams for risk-related clarifications
- Ensured compliance with underwriting guidelines and policy requirements
Senior Executive - MDIndia Health Insurance TPA Private - Pune, India
(2022-11 - 2024-03)
- Specialized in cashless claim processing for health insurance cases
- Scrutinized pre-authorization requests, treatment plans, and medical records
- Coordinated with network hospitals for approval, query resolution, and documentation
- Ensured adherence to policy conditions, medical necessity, and standard treatment guidelines
- Maintained accurate records and timely turnaround for claim decisions
- Developed strong knowledge of TPA operations and hospital coordination
Senior Resident Medical Officer - Rao Nursing Home - Pune, Pune
(2022-03 - 2022-10)
- Provided clinical consultation and patient care services
- Assisted in diagnosis, treatment planning, and follow-up care
- Maintained patient medical records and ensured proper documentation
- Coordinated with nursing staff and hospital administration for patient management
- Gained practical exposure to hospital operations and clinical workflows
