Dr. Vibhuti Amin - BDS,MBA,CPC

Operations Associate

Noida, Uttar Pradesh, India4 yrs 1 mo experience

Key Highlights

Expert in health insurance claims processing
Strong background in healthcare management
Proven track record in fraud investigation

Stackforce AI infers this person is a Healthcare Claims Management expert with a focus on fraud investigation and process improvement.

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Skills

Core Skills

Claims ManagementMedical Claims ProcessingHealthcare

Other Skills

Analytical SkillsCLINICAL SASClaims HandlingClaims ProcessingCollaborative Problem SolvingCross-functional Team LeadershipCustomer Relationship Management (CRM)Data AnalysisDecision-MakingDental InsuranceDental MarketingDental Practice ManagementDental SurgeryExcel PivotFraud Investigation

About

As a Claims Supervisor at Cigna Healthcare, I examine and process various types of health insurance claims, such as inpatient, outpatient, dental, optical, pharmacy, and psychiatry, using standard medical coding systems and software. I also coordinate and resolve administrative denials and appeals, and analyze and research claim data and results to improve the quality and efficiency of health care delivery and outcomes. I have a strong educational background in health care and insurance, with a Bachelor of Dental Surgery degree, a Post-Graduate Diploma in Health Insurance Management, and a MBA in Health/Health Care Administration/Management at Manipal GlobalNxt University, where I learn the latest trends and best practices in the health care industry. I have multiple credentials in this field, such as CPC, ICH-GCP, SAS, and Six Sigma. I am interested in new opportunities that will allow me to apply my skills and knowledge to enhance the customer experience and satisfaction, and to contribute to the growth and innovation of the healthcare sector.

Experience

Cigna healthcare

Claims Supervisor

Jun 2024 – Jan 2025 · 7 mos · Noida, Uttar Pradesh, India · On-site

Control claims cost by all permissible, equitable, fair means.
Responsible for reporting of identified Claims Fraud, Waste and Abuse trends and escalating to concerned stakeholders
Daily monitoring of pipelines and queues on both preauthorization’s and claims processing
Developing training plans for existing and new joiners on preauthorization and claims processing protocols.
Identify gaps in performance and offer coaching to officers as needed. Identify training requirements within the team and perform training sessions.
Preparation of training material
Conducting internal audits on live transactions on daily basis.
Ensuring payer audits files reviewed and providing adequate feedback within agreed timelines.
Monitor the procedural and financial accuracy of team and ensuring that quality parameters are discussed with the reporting team members and improvement on quality to be tracked and reported to managers.

Claims HandlingMedical Claims ProcessingInternal AuditsClaims ManagementFraud Investigations

Care insurance || watania takaful

Claims Manager

Oct 2021 – May 2024 · 2 yrs 7 mos · Gurugram, Haryana, India · Remote

Watania- Noor Takaful Insurance [UAE] - Officer [Pre -Auth]
Headquarters - Dubai
Examine Pre-Hospitalization and make a Pre-Auth decision.
Interpretation of Claims ( IP, OP, Dental, Optical, Psychiatry, Pharmacy)
IP and OP claims Retro Audit
Analyze and research results and make suggestions based on those findings.
Reviews claim requests to determine eligibility for processing and escalate to management if necessary.
Responsible for the coordination and resolution of administrative denials and appeals.
Ability to understand the logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.).
Identify claim(s) with inaccurate data or claims that require review by appropriate team members.
Applying business rules to varying fact situations and making appropriate decisions for the patients.
Assist in a compassionate and effective manner by providing high-quality, ethical services and practising medicine based on current scientific knowledge.

Claims HandlingMedical Claims ProcessingInternal AuditsICD-10StrategyClaims Management

Quicsolv technologies pvt. ltd.

Claims Consultant

Oct 2020 – Sep 2021 · 11 mos · Pune, Maharashtra, India · Remote

Verification, fraud investigation/ Pre and Post
hospitalization documents.
Analysis of observation rates, length of stay, authorizations,
and denials.
Synthesize analyses to facilitate decision making and risk mitigation and incorporate them into project deliverables.
Translate analytical and research results into recommendations.
Claims Interpretation (RR, GR, PA, and MPA) / Medical Examination
Report.
Provide high quality, ethical, patient / Client-centric and practice evidence-based medicine.

Healthcare Information Technology (HIT)Fraud InvestigationData AnalysisClaims Management

United india insurance company limited

Intern

Jan 2020 – Mar 2020 · 2 mos · Raipur, Chhattisgarh, India · On-site

Leading general insurance company wholly owned by the government of India, the health insurance policy covers all members of the family under a single sum insured.
During my internship at United Health Insurance, I did research titled A Study on Awareness of Health Insurance Products and Claim Settlement Procedure.
Roles and Responsibilities
Skilled in internal audit
Ensuring error-free claim processing within turnaround time.
Deficiency retrieval of queries and their settlement.

Ayushman bharat

Medical Officer

Oct 2018 – Sep 2019 · 11 mos · On-site

Ayushman Bharat [PMJAY] Government scheme that aims to help economically vulnerable Indians who are in need of healthcare facilities.
Daily medical scrutiny of claim files.
Investigation of suspected cases
Maintain network hospital relation
Verification of patient at the time of admission.
To assist reporting team lead for handling the daily operations of
claims in network hospital.
Monitor various departmental paramedical and
nonmedical staff for effective utilization of resources.
Assist team lead to design and finalize.
Assist team lead in implementation of investigation
improvement plans.
Solving the quires/concerns of the hospitals related to the services
provided by the scheme.
Feedback from patient for the claim updated and
treatment for fraud regulation.
Assist in investigation of fraud –where I went to patient’s
residence and take out the correct information
and help in fraud regulation where those
two hospitals were deempanlled from network hospital list
Assist in ensuring error free claim processing within turn around
time.
Assist in meeting with clients in case were errors where found from
any side.
Assist team lead for scope of building analytics and
research on the project data (building analytics to
generate key insight) of project data.
Appointee investigator in suspected cases.
Assist in generating deficiency letters for the concerned
departments.
Assist in hospital investigation.
Preparing daily MIS

Healthcare Information Technology (HIT)Healthcare

Goverment dental college raipur

Intern

Aug 2017 – Aug 2018 · 1 yr · Raipur, Chhattisgarh, India

Expertise in dental treatment procedures and patient handling.
Diagnose dental problems in adult,geriatric and pediatric patients.
Performing dental prophylaxis(teeth cleaning),assist in major and minor periodontal surgeries.
Performing tooth extractions and assisting in major and minor oral surgeries
Performing endodontic procedures like cavity filling and Root canal treatment
Prescribing medications for adult,geriatric patients and pediatric patients
Setting a follow up appointment on patients who underwent delicate dental procedures
Educating patients regarding preventive dental care plaque control causes and treatment of dental problems and oral healthcare services.
Conducted various dental check up camps