Shashikumar T V

Senior Medical Officer with extensive experience in health insurance and medical claims adjudication. Currently serving at Mayfair We Care, a leading health insurance provider, with a focus on evaluating clinical documentation, ensuring appropriate claim approvals, and maintaining compliance with medical and insurance guidelines. Proven ability to balance cost-efficiency with patient care standards, collaborate with healthcare professionals, and contribute to the development of fair and effective claim management processes. Adept at clinical decision-making, risk assessment, and ensuring evidence-based outcomes.

• Review and adjudicate medical claims based on clinical documentation and policy coverage.
• Ensure accurate interpretation and application of medical guidelines and insurance policies.
• Identify potential fraud or abuse in claims, and escalate as necessary.
• Contribute to policy development, medical underwriting, and clinical audit processes.
• Provide clinical expertise to support the claims team in decision-making and dispute resolution.
• Ensure compliance with local regulations and organizational standards.
• Participate in medical board reviews and help establish clinical protocols and claim adjudication frameworks.

Dedicated professional with experience in U.S. Healthcare insurance, specifically working with the client Humana as a Senior Process Consultant in the special project team to find overpayments and underpayments for the last year. Here are some of the roles and responsibilities taken care of by me.

• Review, validate, and verify the claims and process as per the guidelines provided by the client.
• Identifying overpayments within the contract.
• Verifying provider contracts and member policies.
• Reviewing authorization and finding duplicate claims.
• Maintained dashboard reports (Production, Quality, BPH) for team tracking.
• Reviewing reprocessed claims and correcting any errors if found.
• Excellent knowledge about co-pay, deductible, co-insurance, and Medicare and Medicaid as well.
• Ensuring the achievement of production and quality targets.
• Teamwork assignment and reporting.