Summary
Overview
Work History
Education
Skills
Accomplishments
Languages
Personal Information
Timeline
Generic

Pooja Keluskar

Mumbai-Jogeshwari

Summary

Seasoned professional with 8 years of experience in Operations and Customer Relationship Management within the Health Insurance domain. Proven expertise in end-to-end process management, ensuring high-quality deliverables and meeting KPI targets. Skilled in strategic planning for continuous process improvement and development, with a strong focus on operational efficiency. Proficient in adopting stringent quality measures, preparing and maintaining reports/MIS to ensure compliance with organizational objectives and standards. Extensive experience in supporting corporate clients and liaising with HR for processing cashless claims, reimbursement claims, and OPD claims. Strong customer-centric approach, with a proven ability to prioritize client needs, resolve escalations within agreed timelines, and maintain high levels of satisfaction and compliance. Skilled in analyzing customer inquiries and issues, ensuring swift and effective resolutions using best practices. Excellent communicator and team player with problem-solving, and multitasking skills, capable of managing tasks efficiently under high-pressure situations.

Overview

10
10
years of professional experience

Work History

Team Leader-Account Management

Medi Assist Insurance TPA
Mumbai
05.2024 - 12.2024
  • Overseeing daily operations, delegating work, and managing schedules and workloads
  • Collaborating with other departments, providing transparent communication, and preparing report
  • Ensuring compliance with company policies and procedures
  • Coordinating with the quality assurance team to ensure service standards
  • Ensuring high levels of customer satisfaction, handling escalated complaints, and providing solutions
  • Shaping the customer experience and driving team performance

Sr. Executive in Corporate Relation

Family Health Plan Insurance TPA
Mumbai
02.2022 - 05.2024
  • Fostered strong client relationships by addressing critical service issues, driving client retention, and supporting both renewals and new business generation
  • Actively contributed to review and renewal meetings with brokers, insurance companies, and corporate clients, focusing on claims resolution and addressing outstanding issues
  • Responded to and resolved client concerns through multiple channels, including email and phone, maintaining high levels of customer satisfaction
  • Effectively managed and resolved client issues, addressing queries, escalations, and grievances to ensure prompt service delivery, including the processing of cashless and reimbursement claims
  • Utilized MIS to efficiently process and clarify claims, ensuring accuracy and timely resolutions

Executive in Corporate Relation

Raksha Health Insurance TPA
Mumbai
06.2018 - 01.2022
  • Managed employee queries, escalations, and grievances, ensuring timely processing of cashless and reimbursement claims
  • Collaborated with internal teams and corporate HRs to resolve escalations and ensure efficient claim follow-ups nationwide
  • Provided dedicated support to retired associates, addressing claims and queries via email and phone
  • Built strong relationships with clients, brokers, and insurers to streamline processes and optimize service delivery
  • Ensured adherence to quality standards and SLAs, driving continuous improvements in customer experience and operational efficiency

Claim Executive

Paramount Health Services TPA
Mumbai
12.2016 - 05.2018
  • Managed end-to-end claim processing, from document collection to settlement, ensuring timely receipt of claim amounts by clients
  • Prioritized claims based on client needs and ensured compliance with insurance policy norms during settlement
  • Addressed customer queries related to claim settlements and provider tariff rates, ensuring clear resolution
  • Conducted audits of claim settlements to maintain high-quality processing standards

Billing & TPA Coordinator

Sushrut Hospital & Research Centre
Mumbai
06.2015 - 12.2016
  • Managed the end-to-end TPA process, including billing, coordinating with TPA companies, and overseeing the pre-authorization process, ensuring timely claim approvals
  • Provided counseling to patients' families, facilitated pre-authorization, and coordinated all activities from patient admission to discharge, ensuring smooth and efficient service delivery
  • Maintained and uploaded patient medical records to the portal for accurate tracking and compliance, while also managing the dispatch of hard copy files to insurance companies for claim processing
  • Administered billing functions, including implant bill updates, reconciliation, and follow-ups with TPAs and insurance companies to expedite health insurance claim clearance

Education

M. Com - Banking and Finance

Mumbai University
Mumbai
01.2015

B.Com - Banking and Finance

Mumbai University
Mumbai
01.2013

H.S.C. -

Maharashtra Board
Mumbai
01.2010

S.S.C -

Maharashtra Board
Mumbai
01.2008

Skills

  • Client servicing
  • Escalation Management
  • Deadline management
  • Verbal and written communication

Accomplishments

  • Resolved client queries via phone and email, ensuring timely, satisfactory resolutions.
  • Adhered to TAT guidelines, minimizing escalations and improving service efficiency.

Languages

  • English, Proficient
  • Hindi, Proficient
  • Marathi, Native

Personal Information

  • Date of Birth: 18/01/1992
  • Gender: Female
  • Marital Status: Married

Timeline

Team Leader-Account Management

Medi Assist Insurance TPA
05.2024 - 12.2024

Sr. Executive in Corporate Relation

Family Health Plan Insurance TPA
02.2022 - 05.2024

Executive in Corporate Relation

Raksha Health Insurance TPA
06.2018 - 01.2022

Claim Executive

Paramount Health Services TPA
12.2016 - 05.2018

Billing & TPA Coordinator

Sushrut Hospital & Research Centre
06.2015 - 12.2016

M. Com - Banking and Finance

Mumbai University

B.Com - Banking and Finance

Mumbai University

H.S.C. -

Maharashtra Board

S.S.C -

Maharashtra Board
Pooja Keluskar