Experience

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  Medusind

  Sept 2017 - May 2018

  Medical analyst

  • Conducting web-based secondary research on Medical, Surgical, Laboratory, Diagnostics and Pharmaceuticals products and procure relevant details. • Validating and analysing the Medical, Surgical, Laboratory, Diagnostics and Pharmaceutical products.• Performing attribute comparison & classify products as per defined standards like Client schema/UNSPSC, etc.

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  Marengo cims hospital

  Apr 2019 - May 2019

  Summer intern

  • Analysed and monitored the process flow of Third-Party Administration (TPA) of cashless hospitalization.• Performed gap analysis of turnaround time in TPA process of the cashless hospitalization.

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  Axa en france

  Feb 2020 - Jul 2023

  • Product planning, designing and liaisoning with the Government bodies & other public entities for building the products.• Assessment of tender RFPs along with preparation of tender summaries, queries for pre-bid meetings, package comparison and providing recommendation for claims management and fraud control.• Supervising the implementation of scheme at ground level by regular physical audits of health care providers and other stakeholders of the scheme.• Managing Government sponsored and other health schemes through outsourced and in-house team.• Monitoring of claims data and identifying the unusual trends & patterns of the claims at various levels like pre-authorization and claims processing and thereby shortlisting of hospitals and claims for audit and investigation.• Allocating and assigning the suspected and unusual claims to the TPAs and other external vendors for investigation and audit• Evaluation of the investigation / audit report and recommending the final action in the claims and against the involved hospitals/insured.• Providing consultancy and training to partner insurance companies & several other stakeholders like TPAs, external vendors, on claim management, fraud control, in designing MOU agreement & SLAs for Private health care providers.• Preparation of briefings/presentation materials for the CEO and other Strategy Heads for meetings with internal and external stakeholders.• Providing assistance to various stakeholders for setting up technology driven solutions.• Provided consultancy to partner insurance and reinsurance companies on process management and fraud mitigation.• Designed innovative business models and strategies in the insurance domain like Captives, Telemedicine, and liaison with the Government bodies & public entities for building the same.• Evaluating the performance of the project by analysing data, generating solutions and providing inputs. Show less • Conducting thorough secondary research on population benefits and other social protection programmes of various International countries and preparing detailed country report.• Performing Data Analysis, identified trends and pattern and use of triggers to check frauds at various levels such as enrolment, pre-authorisation, and claim processing.• Coordinating and collaborating with cedants/clients/vendors and providing them end to end support in designing structure for fraud mitigation strategies.• Supporting the Business development team in documentation, secondary research, and preparing presentations on innovative product lines for Corporates, MSMEs, SMEs, NBFCs, etc.• Developing Standard Operating protocols for processes like empanelment, de-empanelment, Pre-authorisation & claim processing for clients. Show less

  • Assistant Manager Claims & Investigation

    Apr 2021 - Jul 2023

  • Management Trainee Claims & Investigation

    Feb 2020 - Mar 2021
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  Hdfc ergo general insurance

  Aug 2023 - now

  Manager risk and loss mitigation

  • Taking care of Investigation for all products including Health, Critical Illness, PA (Individual & Group).• Controlling Abuse of Insurance by efficiently managing suspicious and fraudulent claims investigation• Handling and managing external vendors for conducting investigation against suspicious claim.• Closely monitoring and looping of investigation findings and subsequently taking actions against erring Agents/Hospital/Customer and Employees• Evaluation of the investigation report along with supporting documents and recommending final action to the claims team against the involved hospitals/agents/customers/employees.• Liaison with Police officials for filling FIRs against fraudsters, customers, hospitals, medical bodies, and other administrative officials• Escalation and Grievance management for the investigated cases and filling complaints to Medical Council against medical bodies for unethical and unfair practices as a part of Fraud Investigation• Daily monitoring and analyzing of the claim data to shortlist, identify the unusual trends, patterns of the claims and fraudulent activities performed by the healthcare providers. Show less