Sports
Gourav Gandhi
Claims Manager
Gurugram
Summary
Effective Medical Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims and Ethical Auto Claims Adjuster with excellent customer service skills to take on multiple cases while meeting strict deadlines. Adept at determining the level of loss for auto claims cases and deciding on a fair compensation for clients. Strong organizational and communication traits.
Overview
10
10
years of professional experience
5
5
years of post-secondary education
3
3
Languages
Work History
Claims Manager
Medical Insurance, Present Care Health Insurance Limited
Gurugram
12.2021 - Current
- Correct errors and omissions on claim and investigate questionable data.
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Ensured all customer communications are professional, accurate, and process claims in a timely manner, as per the required TAT.
- Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims.
- Consistently meet established productivity, schedule adherence and quality standards.
- Documented and communicated timely claims information while supporting accurate outcomes.
- Determined proper course of action for claims processing.
- Handled claims consistent with client and corporate policies, procedures, best practices and regulations.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Evaluated original investigation reports and documents to resolve secondary concerns.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Resolved complex, severe exposure claims using high service oriented file handling.
Claims Processing Specialist
Pramerica Life Insurance Private Limited
Gurugram
09.2020 - 11.2021
- Determine and resolve workload and assignment issues to ensure effective claims processing, expense management and claims disposition.
- Processes assigned claims and determines benefits due pursuant to the client contract; makes timely claims payments and adjustments.
- Remarkable communication and negotiation skills.
- Good computer skills.
- Ability to deal with various types of customers in a professional environment.
- Followed up with customers on unresolved issues.
- Monitored claims processing trends to identify potential areas of improvement.
- Utilized specialized software to process incoming claims, enter data and generate reports.
- Identified and reported potential fraud or abuse related to claims to protect system's integrity.
- Reviewed applications and supporting documents to verify claims eligibility and accuracy.
- Generated, posted and attached information to claim files.
- Checked documentation for accuracy and validity on updated systems.
Claims Manager - Motor Claims
Verma Automobiles - Royal Enfield
Sangrur
05.2013 - 08.2020
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Recognized and resolved issues pertaining to contracts and improper billing procedures.
- Built and maintained close relationships with all payer provider representatives to ensure proper claims processing.
- Exceptional experience in managing claims for all automobile and associate products.
- Outstanding knowledge of ACE coverage and products.
- Ability to analyze data and establish all requirements.
- Ability to monitor tools as per quality assurance processes.
- Negotiated claim settlement agreements to resolve disputes.
- Researched claims and incident information to deliver solutions and resolve problems.
- Passionate about learning and committed to continual improvement.
- Proved successful working within tight deadlines and a fast-paced environment.
- Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
- Learned and adapted quickly to new technology and software applications.
- Strengthened communication skills through regular interactions with others.
- Skilled at working independently and collaboratively in a team environment.
Education
Bachelor of Arts - Economics
Punjabi University
Patiala 05.2010 - 04.2013
12th - Non Medical
Guru Nanak Public School
Sangrur 04.2007 - 03.2008
10th -
Guru Nanak Public School
Sangrur 04.2005 - 03.2006
Skills
Claim Investigation
Claims investigation and research
MS Office Suite
Coverage determination
Legal proceedings knowledge
General Insurance
Claims Handling
Claims Management
Auto Claims
Legal Liability
Medical terms and procedure knowledge
Documentation abilities
Medical billing
Death Claims
Processing medical claims
Damage assessment
Claims Resolution
Insurance regulations knowledge
Interests
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Claims Manager
Medical Insurance, Present Care Health Insurance Limited
12.2021 - Current
Claims Processing Specialist
Pramerica Life Insurance Private Limited
09.2020 - 11.2021
Claims Manager - Motor Claims
Verma Automobiles - Royal Enfield
05.2013 - 08.2020
Bachelor of Arts - Economics
Punjabi University
05.2010 - 04.2013
12th - Non Medical
Guru Nanak Public School
04.2007 - 03.2008
10th -
Guru Nanak Public School
04.2005 - 03.2006