AKhilesh Ajay

MBBS graduate with experience in medical claims adjudication, CGHS claim scrutiny, healthcare administration and clinical documentation. Experienced in reviewing reimbursement and cashless claims, evaluating medical records, ensuring compliance with government healthcare guidelines, coordinating with empanelled hospitals and supporting accurate claim settlement. Strong analytical, communication and decision-making skills with a keen interest in Health Insurance TPAs, utilization review and medical auditing.

Medical Officer – CGHS Claims Processing - State Health Authority, Uttarakhand - Uttarakhand

(2026-04)

• Scrutinize CGHS reimbursement and cashless claims.
• Review discharge summaries, prescriptions, investigations and hospital bills.
• Assess medical necessity and claim admissibility.
• Ensure compliance with CGHS policies and package rates.
• Coordinate with hospitals to resolve deficiencies.
• Maintain documentation and prepare claim reports.
• Support timely settlement and quality assurance.

Clinical Observer (Observership) - Chauhan Medicity

(2021 - 2021)

6 Months

• Observed OPD, IPD and emergency workflow.
• Assisted in clinical documentation and case discussions.
• Gained exposure to patient management and multidisciplinary care.

MBBS - Medicine - Harbin Medical University

Class XII - DAV School, Baghni, Nurpur

Class X - DAV School, Baghni, Nurpur