Dr S. Manjunath(P.T)

Claims benefit contract configuration is the process of setting up and managing the contractual agreements between healthcare providers and payers within an organization's claims system. This involves translating the terms of a contract into system rules that govern how claims are processed and paid.

This configuration includes details about:

• Benefit setup: Defining what services are covered, including co-pays, deductibles, annual maximums, and any restrictions on coverage (e.g., only certain medications or treatments).
• Claims adjudication rules: Establishing how claims are evaluated, and either approved, denied, or modified based on the contract’s parameters.

Worked as a Senior Manager in Claim Audit from 2019 to 2022.

Conducted audits of medical claims to identify errors and discrepancies.

• Conducted audits of medical claims to identify errors, discrepancies, and potential fraud.
• Ensured compliance with relevant regulations (e.g., [mention specific regulations]) and company policies.
• Analyzed claims data to identify trends and areas for improvement in claims processing.
• Collaborated with other departments to resolve claim-related issues.
• Prepared and presented reports on claims audit findings.
• Developed and implemented new procedures to improve claims processing efficiency.

• I worked with Karthika Insurance as an AGM of Operations.
• Primarily involved in working with management and developing project plans, as well as the implementation of internal application processes.
• Team management.
• Resource allocation and monitoring.
• Monitoring the productivity and quality of the assigned team.
• Perform quality assurance audits and process reviews.
• Follow up with customers, IT apps, and other stakeholders to get the required information and resolve.
• Analyze findings from process reviews, and develop reports to highlight trends and opportunities for improvement.
• Make the first level of medical scrutiny for all medical claims for a hassle-free process, and to help reduce the process.
• Advice on insurance eligibility.
• Helping the customer to choose the right insurance coverage.
• Analyzing the insurance benefits eligible for, service assistance for esteemed.
• Complete guidance on insurance policy benefits and exclusions.
• Organizational Experience:

• Worked with Vidal Health as a senior manager. Primarily involved in Work with Management and develop project plans to address opportunities identified through process reviews for Dubai Health Authority and Health Authority Abu Dhabi
• Communicating the requirement to developers through Business solutions
• Implementation of automation process of PBM (Pharmacy Benefit Management) process for DHA process.
• Responsible for activities in Enrolment, Approvals dept,Claims management, Call Center.
• Developing and Establishing standard operating procedures for various activities in organisation.
• Liasoning with regulatory bodies to streamline the functioning of the organisation.
• Automation of business process is the main area of concern. Creation and management of the clinical rules which will assist in automated claims and pre-authorization adjudication, This automation will impart 80% claims get adjudicated in real time.
• Scrutiny of Medical Claims, computation of loss and settlement of medical insurance claims for the following Corporates.
• AL SHAFAR, Auroro Drug Store LLC, BeautyMax LLC, Dubai Enhanced Plan 1, Eversendai, Globelnet TPA (L.L.C), INTERTEC Systems LLC, Jumbo Group-Dubai - Cat C / Cat D, Kent College, Mahy Asacana Cat A -VIP, Mahy Asacana Cat B, Mahy Asacana Cat C, New England Enterprises, Universal Islamic Meat FZCO -Dubai Enhanced Plan 1

• Requirement Elicitation from the client along with impact analysis.
• Functional requirements documentation as per the need of the stakeholder.
• Preparation of BRD & SRS
• Communicating the requirement to developers through B.R.D & D.F.D
• Transferring Knowledge to Engineering & Testing team
• Writing and implementing Test cases, System testing, User Acceptance Testing, Regression Testing and maintaining Requirement Traceability Matrices.
• Proficient in Defect Management and logging and Tracking of issues.
• Co-ordination with offshore and onshore teams.
• Develop and maintain high quality of communication-written (mails and documentation) and verbal (conference calls, presentation etc.).
• Involved in training peers on Health Insurance Domain.
• Area of Expertise
• Defining Scope Business Area, Analysing & gathering Business requirements & preparing SRS documents (Software requirement specifications) Requirement Elicitation and Analysis.
• Functionality Enhancement.
• Functional and User Acceptance Testing.

• Company Overview: (TPA for Insurance companies)
• Worked as Senior Manager in Internal Claims Audit. Primarily involved in auditing the claims processed by the medical persons
• Team management
• Resource Allocation and monitoring
• Monitoring Productivity and Quality of assigned team
• Perform quality assurance audits and process reviews
• Follow-up with customers, IT Apps, & other stake holders to get required information and resolve
• Analyse findings from process reviews and develop reports to highlight trends/ opportunities for improvement.
• Make recommendations to help reduce process variation and eliminate errors.
• Work with top executives and develop project plans to address opportunities identified through process reviews.
• Escalate unresolved issues to Vice President and work with Executive bodies to resolve the issues.
• Providing innovative solutions for process improvements
• Motivating team members by nominating them for reward and recognition
• Performance Management & Appraisal Management

• Managing CGHS & ECHS Claims Adjudication
• Office in charge for TPA Claims Audit
• Scrutiny
• Computation and settlement of Central Government Health Scheme medical claims.
• TPA Audit team and handling the complete TPA Audit MIS and providing solutions to the Insurance Companies in regard to effective claims settlement.
• People Management

• Company Overview: (TPA for Insurance companies)
• Managing the Pre – Authorization Team.
• Ensure claims are processed within the specified TAT by the Pre-Authorization Team.
• Set Targets and responsibilities for every member if the Team.
• Streamlining of the Pre- Authorization Process.
• Implementation of new processes to improve the performance of the Pre-Authorization Team.
• Risk Management and Liability Check.
• Approval of Cashless Requests.
• Performance Reviews of the Team.
• Co-ordination with hospitals and respective branches.
• Interaction with customers and Clients.
• Analysis of Team Performance with respect to Quality, TAT, Customer Satisfaction and Dissatisfaction
• Training for new recruits.
• Staffing and Scheduling
• Recruitment
• Worked as a Domain expertise for the End User Application which was outsourced to HP Company

• Health care Analysis (Radiology Dept).
• Code Research
• Coding Methodology: ICD9 – CPT.
• Review claims data to ensure that assigned codes meet required legal and insurance rules and that required signatures and authorizations are in place prior to submission
• Providing Training on ICD 10 Coding
• Utilizing specialized medical classification software to assign procedure and diagnosis codes for insurance billing.

• Company Overview: (TPA for Insurance companies)
• Scrutiny of Medical Claims, computation of loss and settlement of medical insurance claims.
• Claims Adjudication
• Executing process of online claims transactions.
• Statistical analysis of claim type after medical coding of the claims (ICD 10).

• Worked as Consultant Physiotherapist with Clinical experience from Feb 1999 to Aug 2004.
• Involved in rehabilitation of people requiring Physical therapy.
• Specialized in Orthopaedic and Neurological conditions.