Balaji Rekha

A performance-driven Claims Officer with over 7 years of expertise across the health insurance and healthcare sectors. Adept in end-to-end claims handling—from verification and processing to settlement and complex escalation management. Extensive knowledge of OP/IP hospitalization claims, preapprovals, and medical billing procedures. Proven ability to bridge clinical documentation with insurance policy requirements to ensure service excellence and operational efficiency.

Claims Team Lead & HO QC Auditor at NLGIC SUPPORT SERVICES PVT LTD (2017-05 – Present)

• Team Leadership: Manage and lead a dedicated claims audit team, ensuring the highest standards of quality and efficiency in health insurance processing.
• Quality Control: Conduct rigorous Head Office Quality Control (HO QC) Audits to review processed claims, identifying technical errors and ensuring 100% policy compliance.
• Adjudication: Execute end-to-end claims adjudication, encompassing the entire lifecycle: verification, validation, and final settlement approval.
• Specialized Claims: Manage a diverse portfolio including Inpatient (IP), Outpatient (OP), and Cashless claims, verifying eligibility and completeness.
• Appeals & RCA: Handle complex claim denials and appeals; perform Root Cause Analysis (RCA) to identify process gaps and implement corrective actions.
• Fraud Mitigation: Spearhead fraud detection initiatives by identifying irregular billing patterns and documentation discrepancies.
• Policy Analysis: Evaluate detailed policy coverage including exclusions, sublimits, and pre-existing condition (PED) clauses.
• Compliance: Ensure all workflows strictly adhere to IRDAI guidelines and internal organizational audit standards.
• Data Management: Maintain high-fidelity documentation and data entry within claims management systems.
• Process Improvement: Generate MIS audit reports to track error trends and lead process optimization initiatives.
• Training: Mentor team members to improve productivity, processing accuracy, and overall quality scores.

Medical Billing Executive at BILLROTH HOSPITAL (2016-01 – 2017-04)

• Billing Lifecycle: Directed end-to-end medical billing operations for both Inpatient (IP) and Outpatient (OP) hospital services.
• Hospital Tariffs: Prepared and submitted accurate hospital bills in strict accordance with treatment records and pre-defined hospital tariff structures.
• Clinical Liaison: Coordinated closely with doctors, nursing staff, and medical departments to ensure documentation was complete and correct for billing.
• Pre-Billing Audit: Verified patient demographics, insurance coverage, and medical treatment codes before final invoice generation.
• Claim Facilitation: Handled both cashless and reimbursement cases, ensuring all necessary documentation was ready for seamless insurance claims.
• Invoicing: Generated diverse billing types including final bills, discharge summaries, and interim patient bills with zero financial leakage.
• Rejection Management: Reviewed and corrected billing discrepancies at the source to minimize rejections and processing delays.
• Records Maintenance: Maintained meticulous patient files and billing records in compliance with hospital and healthcare standards.
• TPA Coordination: Acted as the primary point of contact for Insurance and TPA teams for query resolution and claim clarifications.
• Policy Adherence: Guaranteed strict adherence to hospital pricing policies, internal guidelines, and external regulatory standards.
• Financial Reconciliation: Assisted in the reconciliation of patient bills and payments to ensure 100% financial integrity.
• Volume Handling: Successfully managed high-volume billing operations while maintaining strict Turnaround Time (TAT) targets.

Master of Computer Applications in Computer Applications – T.J. Institute of Technology (2011)

Bachelor of Computer Applications in Computer Applications – Thanthai Hans Rover College (2008)

Higher Secondary Certificate – Dominic Girl's Higher Secondary School (2005)

Secondary School Leaving Certificate – Dominic Girl's Higher Secondary School (2003)