Prince Mathew

Foreign-trained physician (MBBS) with over 8 years of experience in medical claims adjudication, medical records review, insurance policy interpretation, fraud detection, and healthcare operations. I have a proven ability to analyze medical documentation, review claims for accuracy and compliance, identify discrepancies, and collaborate with multidisciplinary teams to resolve complex cases. I am seeking a non-clinical role in healthcare insurance, claims, compliance, or operations.

ASSISTANT MANAGER – HEALTH CLAIMS - ACKO General Insurance - India

(2022-01)

• Performed medical claims adjudication by verifying documentation, eligibility, provider details, and billing accuracy to determine valid payouts.
• Conducted medical records review to confirm treatment details and policy compliance, improving claim clarity and decision consistency.
• Identified potential fraud indicators and referred suspect cases to investigations, contributing to reduced fraudulent payouts.
• Interpreted insurance policy terms and coverage limits to resolve claims accurately and ensure correct claim outcomes.
• Collaborated with audit, billing, and customer service teams to resolve complex or escalated claims, shortening resolution cycles.
• Communicated with healthcare providers to clarify treatment details, correct coding issues, and address documentation gaps for faster processing.
• Trained team members on claims review procedures and fraud detection methods to raise review quality and team capability.
• Supported process improvement initiatives to increase claims processing efficiency, delivering measurable reductions in handling time.
• Recognized for improving claims review accuracy and supporting fraud detection efforts with measurable quality improvements.
• Consistently managed high-volume and complex claims cases while maintaining quality and timely adjudication.

MEDICAL CLAIMS AND INSURANCE SPECIALIST - Hospitals and Insurance Organizations - India & UAE

(2012-01 - 2020-12)

• Reviewed and processed complex medical insurance claims to ensure policy compliance and timely payment decisions.
• Analyzed medical records and documentation to validate clinical coding and reduce claim inaccuracies.
• Coordinated pre-authorizations and approvals with providers and payers to accelerate care delivery and claim flow.
• Supported audits and compliance reviews by preparing detailed billing and documentation summaries for reviewers.
• Maintained organized claims records and generated operational reports to track performance and identify trends.
• Responded to provider and policyholder inquiries to resolve coverage questions and update claim status.
• Resolved disputed and escalated claims through targeted investigation and negotiated settlements to close cases efficiently.
• Interprets policy language to make defensible coverage determinations and documents rationale clearly, reducing escalations and supporting compliance reviews.

CLINICAL DOCUMENTATION AND SUPPORT EXPERIENCE - Hospital Settings - India

• Assisted physicians by preparing discharge summaries and treatment notes to maintain accurate clinical records for care continuity.
• Maintained detailed medical documentation to support insurance claims and audit readiness with consistent accuracy.
• Coordinated clinical information across teams to ensure patient records were complete and accessible for decision-making.
• Designed and implemented a patient-record intake workflow that improved information completeness and enabled faster clinical decisions, yielding measurable reductions in follow-up clarifications.

BACHELOR OF MEDICINE, BACHELOR OF SURGERY - MBBS - International University of the Health Sciences