PROFESSIONAL HIGHLIGHTS
Organization: EUROP Assistance from Sep’2009 to Aug’2013
Current Designation: Manager – Claims (Operations)
Europ Assistance is the world’s leading assistance organization with an established presence in 208 countries and territories. Its ambition is to support individuals and companies in every life situation, from the most exceptional to the most routine. Providing assistance anywhere in the world, solving complex problems 24 hours a day, 365 days a year over the course of the last 45 years, the Europ Assistance Group has acquired unrivalled know-how and expertise through the collective efforts of over 5,500 employees and 37 Alarm (Call) Centers across the globe.
Work Profile:
CLAIMS MANAGEMENT
- Authorized to decide on all medical and non-medical claims and accordingly repudiate or settle claims.
- Direct and monitor the activities of Claims Administrators in assessment of high value claims, query handling, calls received related to Medical & Travel Insurance Product.
- Handling the approvals/assessment and reconciliation of outpatient & inpatient claims. Capable of interacting with doctors and training non medical staff on insurance terms and process.
- Expertise in handling medical & travel claims.
- Achieving productivity targets with respect to processing guidelines as per the agreed norms.
- Adhering to the quality standards as detailed in the objectives by ensuring accuracy requirements are met as per the target.
- Identify areas for Process Improvement or Cost Efficiency and ensure functional coordination to ensure implementation of Guidelines or System Enhancements.
- Optimal Utilization of resources as part of work planning.
- Weekly Trend Analysis reporting.
- Meeting the TAT for the process.
- MIS generation for all Insurer’s on weekly/Month Basis for all outstanding/paid/denied claims both reimbursement and cashless cases.
- Responsible for Relationship Management across all clients & ensure smooth interface between the various departments.
- Handle relationships with brokers/corporate HR's regarding reimbursement & cashless claims by asking for additional information whenever required; by explaining the details of settlement (application of the deductible and coverage, justify rejections and uncovered expenses.
- Implementation of new process in Health claims management for speedy settlement of claims.
- Inputs to IT team for system up gradation as per the client’s requirements.
- Well versed with ICD (International Coding System), CPT (Common Procedural Terminology) and HCPCS (Healthcare Common Procedural Coding System) billing codes.
- Investigation of Fraud and Detected potential frauds in claims processing and advice insurer's not to issue policies to fraudulent insured's.
- Liaison with Insurance Company for policy related issues.
- Managed Audits with Insurance companies on quarterly basis.
- Management of the relationship between other offices and medical providers which includes discussing cases updates, verifying cost for such treatment in relation to agreed rates and negotiate the cases with medical providers.
COMPLIANCE
- Maintain systematic filling and documentation.
- Preparation of internal process flow between Operations, Claims and Finance and their implementation.
- Ensure all reports/correspondences to clients are checked for accuracy and professional presentation.
- End to End Automation.
- Process Audits, tracking of manual processes and controls.
- Preparation of claim procedure and process flow for clients.
PORTFOLIO MANAGEMENT
- To identify and undertake any given projects as agreed with the higher management.
- Preparing different kind of analysis for management and for clients on monthly and quarterly basis.
- Analysis on the Incidence rate, average claim size and Loss ratio for Insurer’s.
- Performance Appraisal of the Operations Executives.
- Induct and carry out recruitment, capability and disciplinary processes when required in conjunction with HR.
- Sharing view to insurer’s on underwriting of the travel product.
- Sharing Different reports to Insurer’s for their corporate Portfolio
TRAINING
- Preparation of training content for entire team.
- Giving Presentations and training to associates on product, policy T&C & several computer systems and application.
- Manage claims team through Coaching and Mentoring.
INTERNATIONAL SOS PVT. LTD: - Duration: September 2005 to August 2009
Position:Supervisor Claims
Company Profile: International SOS is the world’s leading provider of medical assistance, international healthcare, Security services and outsourced customer care. With over 6,000 professionals operating in 70 countries, we help organizations manage the health and safety risks facing their travellers, global workforce and customers.
Clients:Insurance companies; Individuals; Telecommunications; Banking and credit card
JOB Profile:
- Managing Claims Administrators team for day-to-day activities like Claims Processing, query handling, calls received at domestictoll free line related to Overseas Travel Insurance Policy within a reasonable time frame to meet SLA's.
- Monitoring productivity of the team members.
- Provide training to the new team members and doing quality check.
- Conducting fortnightly call to the clients for the claims updates.
- Responsible for conducting periodic meetings with Managers on steps to improve performance of a particular executive and a team as a whole.
- Handling overseas travel insurance for six Insurance companies.
- Getting settlement done for claims, which needs clearance from Insurance Company.
- Interdepartmental coordination for Claims processing issues.
- Handle relationships with client and brokers regarding reimbursement claims by asking for additional information whenever required.
- MIS generation for claims on weekly & monthly basis; data analysis for Insurance quarterly reviews.
- Coordinating with the medical providers which includes discussing treatment, verifying cost for such treatment in relation to agreed rates and negotiate the cases with medical providers.
- Coordinating with overseas offices & medical team for claims settlement.
- Handling disputes related to claim rejection and uncovered expenses.
MED SAVE HEALTH CARE INDIA LTD-Duration: April 2003 to August 2005
Position: Claims Executive
Company profile - Med Save Health Care Ltd. is 40:60 joint ventures between Med Save USA and its Indian Promoters. It is a BPO unit involved in Health Insurance, back office operation etc. It is among the largest Third Party Administrator (TPA) servicing mainly in Claim Handling, Claim management, Assistance services etc.
Clients: ICICI Lombard General Insurance Co Ltd., New India Assurance, National Insurance, United India Insurance and Oriental Insurance
JOB Profile:
- Claims processing; updating queries online, coordinating with medical team for settlement of claims as per the terms & conditions of policy
- Prepare Case summary and settlement of Claims.
- Coordinating with Insurance companies for payments and timely reporting for claim ratio.
- Liaison with Insurance Company for endorsements & policy related issues. Checking policies & endorsements from Insurance Co.
- MIS Generation.
Career Highlights:
- Core team member of the new software deployment team for EUROP ASSISTANCE India
- Received an out of turn promotion to a Supervisor Claims due to an exceptional delivery of service to Insurance client at International SOS 07-08 & 08-09.
- Performance excellence award for the month of November’09 for Setting up the claims department and system development for Insurance clients
- Received appreciation from ICICI Lombard for Managing clear Audit’s.
- Passionate employer award for FY 08-09
Educational QUALIFICATION
- BBM from Royal Institute of Management Studies.
- MBA from Royal Institute of Management Studies.
PERSONAL DETAILS
Year of birth : 1983
Sex : Male
Language known : English, Hindi & Punjabi
Marital status : Unmarried
Hobbies : Reading Newspapers, Playing Cricket & Listening to Music
Ankur Sawhney
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