Sudhir Penkar

<p>Systematic examination of Religare Health Insurance companies (CHIL) medical, billing records, and other relevant information in order to ensure accuracy, compliance to justify the claim.<br>
Primarily determination of the quality of medical records, deductible amount in medical billing and submission of this medical summary on their dedicated portal.<br>
Identify any discrepancies, errors, or deficiencies in documentation or practices that could impact on patient care.<br>
Critical appraisal of planning, implementation and evaluation of services in terms of efficiency, effectiveness and quality.<br>
Measuring a clinical outcome or a process against well-defined standards set on the principles of evidence and identify possible misrepresentations.<br>
Perform risk assessments on potential loan recipients based on credit rating and check medical conditions rating on Munich Re Internet Risk Assessor (MIRA) portal, which covers related to risk assessment before underwrite the policy and borrowing history, and other specific risk factors.<br>
Record loan denials and specific basis for declining application.<br>
Monitor and report noncompliance with loan covenants.</p>

<p>Systematic examination of Religare Health Insurance companies (CHIL) medical, billing records, and other relevant information in order to ensure accuracy, compliance to justify the claim,  Primarily determination of the quality of medical records, deductible amount in medical billing and submission of this medical summary on their dedicated portal.  To identify any discrepancies, errors, or deficiencies in documentation or practices that could impact on patient care.  Critical appraisal of planning, implementation and evaluation of services; in terms of efficiency, effectiveness and quality.  Measuring a clinical outcome or a process, against well-defined standards set on the principles of evidence and identify possible misrepresentations.  Perform risk assessments on potential loan recipients based on credit rating and check medical conditions rating on Munich Re Internet Risk Assessor (MIRA) portal, which covers related to risk assessment before underwrite the policy and borrowing history, and other specific risk factors. Record loan denials and specific basis for declining application. Monitor and report noncompliance with loan covenants.</p>

<p>Evaluation life members enrollment form.<br>
Validation of group life insurance death certificates.<br>
Assessment of group life insurance claim (death and critical illness) documents such as certificate of insurance, medical documents, life insurance enrollment form, and coverage details etc.<br>
Recommendation for payout or repudiation / additional documents.<br>
Coordinating with master policyholder and internal department persons.<br>
Training other team members.</p>

<p>Develop underwriting knowledge and decision-making skills of RGJAY / MJPJAY (Rajiv Gandhi Jeevandayi Arogya Yojana and Mahatma Jyotiba Phule Jan Arogya Yojana) Mass policy (Social Health Insurance) E - Claims, Maharashtra Government.<br>
Evaluate the fully underwritten health applications, approving or rejecting applications ensuring compliance with underwriting adjudication guidelines and specific state requirements across 7 district of Maharashtra.<br>
Maintain knowledge of Mass policy product underwriting guidelines of 971 medical / surgical procedures.<br>
Keep abreast of compliance RGJAY / MJPJAY adjudication guidelines and state specific regulations of Mass policy in team.<br>
Respond to declination / appeal inquiries using established procedures to upper hand (Nodal Agency : RGJAY Society (SHAS) or Insurer (NIC).<br>
Complete review of prescription, Lab. Reports, X-Ray or ECG etc.<br>
Find trigger points of fraud (misrepresentation) claims and provide inputs to Investigation Department for field investigation, if any.<br>
Auditing of E - Claims of each team doctors.<br>
Build claims teams morale for maintaining TAT (Turn Around Time) period.<br>
Refer all counter-offs or medical declines to the C.M.O. (Chief Medical Officer) or Project Head for review of specific medical cases.</p>

<p>Supervising and adjudicating (validation) of CGHS (Central Govt. Health Scheme) OP (out patient) and IP (indoor patient) claims with the help of prescribed Central Govt. rate lists and their guidelines.<br>
Impart medical knowledge, terminology and subsequent consultation on Lab. Test, medical procedures to in-house and executive staff on CGHS OP claim settlement.<br>
Solve queries effectively in this regard.<br>
Develop new proficiency regarding latest CGHS updates and communicate effectively with team members.<br>
Interpreting medical knowledge and procedures to internal audit on CGHS OP E - claims.<br>
Develop business with the help of Dept. Head, CGHS additional director and maximizing revenue for the company by empanelling new hospitals on board.<br>
Medical codification of ICD code – 10 exclusively done single handedly.</p>

<p>Supervision and data entering of different health policies for different companies and organizations into the main frame of computer system.<br>
Discuss the rejected claims with related doctors and draw up strategies to minimize the claim ratio.<br>
Handle claim rejections and deductions of bills for individual policies subject to insurance guidelines and adjudicating the claims as per policy terms and conditions.<br>
Handling all claim related queries and resolving the same of potential policy holders.</p>

<p>Approve group mediclaim.<br>
Handle all claim related queries and resolve the same of potential policy holders.<br>
Regular interaction with clients on key issues.<br>
Reconciliation of individual claims on daily basis.</p>

<p>Scrutinize the cashless and reimbursement health insurance claims of PSU insurer.<br>
Recommend or non admissible the cashless or reimbursement claim as per policy terms and condition.<br>
Liasioning with the PSUs insurance companies to resolve medical related issues if any.<br>
Resolving any claim related issues for individual clients and maintain T.A.T. of the same.<br>
Regular corporate liasioning and ensuring prompt and enhanced servicing parameters.<br>
Coordination with branch offices and regional offices for claim process and disbursement, help desk etc.</p>

<p>Provide quality Ayurvedic treatment and counselling to the patient and their families on OPD basis and convince them for the various Ayurvedic therapies.<br>
Organize and establish state wise Ayurvedic therapy centers and develop potential customers for the promotion of therapy and impart knowledge of the same.</p>

<p>Examine and evaluate OPD patients and render quality treatment to poor and under privilege on daily basis to villagers.<br>
Organize and coordinate with various Medico Consultants for Annual Health Camp.<br>
Promote and implement social hygiene management to villagers in terms of techniques and prevention of health hazards.</p>

<p>Attend all surgical emergencies referred from Casualties to prepare the patient for pre operative procedure and tracing their investigation with respect to surgery.<br>
Perform all minor surgeries individually and assist major surgeries to operating surgeon.<br>
Preparing OT list of scheduled operations.<br>
Attend OPD’s of designated surgical unit incharge to follow up and review of admitted and post operated patients with Head of the Department.</p>