Dr. P K B

As the leader of a team comprising more than five healthcare professionals across Pan-India my primary objective is to boost profitability and customer satisfaction through effective health data analysis. With extensive experience in the healthcare industry, covering both corporate and retail products, as well as mass death policies, I have honed my skills as a dynamic and result-oriented professional, capable of planning, executing, monitoring, and balancing resources to achieve desired outcomes. I am adept at managing multiple functions and activities in high-pressure environments, with a proven track record of meeting tight deadlines.

My high-integrity, energetic leadership style is underscored by my ability to create successful outcomes in complex situations. I possess an executive-level understanding of operation management and am passionate about supporting and serving others with enthusiasm, energy, inspiration, and expertise. I am willing to shoulder responsibility and am committed to achieving more as a team appraiser.

On role-Experienced professional specializing in on-ground verification, report writing, hospital visits, and insurance claim investigations - ICICI LOMBARD GENERAL INSURANCE CO.

(2024-11-06)

Skilled in handling reimbursement claims, benefit claims, and indemnity policies with a strong focus on accuracy, compliance, and transparency. Responsible for conducting detailed insured residence verification, coordinating with hospitals and treating doctors for medical justification, and preparing comprehensive investigation reports. Adept at quality assessment, field investigation, and ensuring timely and precise documentation to support claim decisions.

Known for strong attention to detail, analytical thinking, and dedication to delivering accurate and transparent reports, making a valuable contribution to organizational efficiency and claim integrity.

Off-Role Consultant for Report Writing (Reimbursement, Personal Accident, TTD claims, Benefit policy, Indemnity policies) - Total Transparency Investigation

(2022-07 - 2023-10)

• Responsible for report writing on a per-case basis.

Off-Role Consultant - VM Integrated Service - Uttar Pradesh, Gujarat, and Mumbai

(2022-03 - 2023-07)

Heading operations across Uttar Pradesh, Gujarat, and Mumbai for Max Niva Bupa & FHPL Insurance TPA, SBI General Insurance, and IFFCO-Tokio Insurance.

• Responsible for improving investigation quality, maintaining turnaround time (TAT), and preparing comprehensive final investigation reports with accuracy and transparency.
• Handling escalations effectively and ensuring timely resolution of operational and claim-related issues.
• Planning and conducting training programs for team members handling health and life insurance cases, while developing investigation officers' skills in fraud detection and case assessment.
• Providing continuous guidance, support, and skill development training to team members to enhance operational efficiency and investigation standards.

Team Lead - Health Claims Verification and Life Claims Investigation - Digi-Verifi Pvt. Ltd. - Gujarat and Delhi NCR

(2021-12 - 2022-02)

• Overlook a team of over 15 professionals in Gujarat and Delhi NCR responsible for health claims verification.
• Lead a team of more than 5 professionals in Gujarat, Madhya Pradesh, Rajasthan, and Delhi NCR responsible for investigating life claims for corporate clients of ICICI PRU and Max Life.

Administrator - FAMS (Fraud and Abuse Management) - Sharak Health Care Pvt. Ltd.

(2016-01 - 2021-03)

Conducting health data analysis and generating MIS reports to identify claims trends, suspect cases, and potential fraudulent activities for early fraud and abuse detection.

• Managing fraud and abuse control operations, including supervision and coordination of field investigation teams.
• Involved in handling mass insurance policies and supporting the setup, recruitment, and management of human resources for large-scale schemes such as MKSBY.
• Preparing productivity and performance reports for individual team members to monitor operational efficiency and team performance.
• Conducting regular training sessions for team members focused on fraud detection, prevention techniques, and investigation best practices.

Team Lead - Health Claim Investigation - M/S Prompt Investigator, Delhi - Delhi

(2015-01 - 2015-12)

Led external health claim investigation teams and prepared detailed investigation reports with accuracy and transparency.

• Maintained turnaround time (TAT) while ensuring early detection of fraud and identifying suspicious claims for further investigation.
• Managed health claim investigations for major corporate clients, including MAX Bupa, Religare, HDFC ERGO, Bajaj Allianz, and TTK-SIGNA.
• Worked on life insurance investigations for clients such as L&T and DHFL (PA), handling verification and claim assessment processes efficiently.

Medical Officer - Medi Assist India TPA Pvt. Ltd., Delhi - Delhi

(2010-08 - 2014-12)

Conducted hospital investigations and verifications, insured verification, vicinity checks, and medical store/pharmacy investigations as part of claim assessment and fraud detection processes.

• Successfully identified fraudulent claims, resulting in savings of over INR 1 million for the insurance company.

Bachelor of Homeopathic Medicine and Surgery - BHMS - Vikram University, Ujjain (2007 - 2008)

HSSC - MP Board (2000)

HSC - MP Board (1998)