Summary
Overview
Work History
Education
Skills
Accomplishments
Languages
PERSONAL INFORMATION
Timeline
Generic
Shivakumar S

Shivakumar S

K R Puram, Bangalore

Summary

Results-driven Claims Specialist with expertise in auditing reimbursement and cashless claims at Acko General Insurance Pvt Ltd. Proven ability in fraud detection and effective time management, ensuring compliance and accuracy. Recognized for enhancing team performance through strategic allocation and collaboration, consistently achieving turnaround times within stipulated limits.

Overview

8
8
years of professional experience

Work History

CLAIMS SPECIALIST

Acko General Insurance Pvt Ltd
Bangalore
10.2022 - Current
  • Processing Claims: Review and process reimbursement claims in accordance with company policies and guidelines.
  • Claims Auditing: Audit both reimbursement and cashless claims to ensure accuracy, compliance, and completeness.
  • Task Allocation & Monitoring: Allocate audit claims to appropriate team members, and monitor the claims dashboard every 2 hours to maintain a consistent turnaround time (TAT) of 2 hours.
  • Escalation Management: Handle escalated claims through Freshdesk, including resettlement cases, and priority escalations.
  • Fraud Detection: Conduct fraud checks by reviewing past claims history, hospital infrastructure credibility, and system-triggered alerts.
  • Claim Settlement Verification: Verify claim settlement letters, focusing on deduction breakdowns, and final payment amounts.
  • Bank Account Validation: Ensure the bank account details match the main beneficiary’s name and information before settlement.
  • Reporting: Prepare and share consolidated weekly reports of team activities and performance with management.

CLAIMS PROCESSOR

Vidal Health TPA. Pvt Ltd
Bangalore
01.2022 - 10.2022
  • Claims decisioning: Approve or reject claims after conducting all necessary validations and checks.
  • Escalation Management: Handle escalated cases, and ensure timely and effective resolution.
  • Query and Discrepancy Resolution: Address and resolve queries or discrepancies related to claims processing.
  • Follow-ups on Pending Cases: Actively follow up on open or pending claims to ensure closure within stipulated timelines.
  • TAT Compliance: Monitor and ensure adherence to turnaround time (TAT) for all claim-related processes.
  • Cross-functional Coordination: Collaborate with internal departments to facilitate swift resolution of escalations and grievances.

CLAIM PROCESSOR

Mediassist India TPA. Pvt Ltd
Bangalore
10.2017 - 02.2021
  • Processed reimbursement claims efficiently and accurately.
  • Conducted training sessions for new joiners to enhance onboarding experience.
  • Managed Management Information System (MIS) for streamlined operations.
  • Responded to grievance and escalation emails and calls from insurer and escalation platform.
  • Assisted customers with claim document submission while clarifying queries, deductions, or denials.

Education

Bachelor of Arts -

Y.E Rangaishetty College, Pavagada
Tumkur University
01-2012

Diploma in Computer Applications (DCA) -

MICE
Pavagada
01-2010

Skills

  • Auditing of Reimbursement & Cashless Claims
  • Documentation Review & Compliance Checks
  • Settlement Determinations & Claims Assessment
  • Claims & Query Review for Accuracy and Completeness
  • Allocation and Workflow Management for Claims Processing
  • Strong Teamwork and Collaboration Skills
  • Effective Time Management Abilities
  • Proficiency in Management Information Systems (MIS)
  • Data Mapping and Analysis Expertise
  • Fraud detection

Accomplishments

  • Best Performance Award – Recognized 3 times in 2024 at ACKO General Insurance for exceptional contributions to auditing claims, demonstrating a strong focus on quality, accuracy, and productivity. Consistently maintained high audit standards while contributing to process efficiency and error reduction

Languages

Kannada
First Language
English
Advanced (C1)
C1
Hindi
Beginner
A1
Telugu
Proficient (C2)
C2

PERSONAL INFORMATION

  • Name : Shivakumar S
  • Father: Siddappa
  • Mother : Shivamma
  • Date of Birth : 07/06/1991

Timeline

CLAIMS SPECIALIST

Acko General Insurance Pvt Ltd
10.2022 - Current

CLAIMS PROCESSOR

Vidal Health TPA. Pvt Ltd
01.2022 - 10.2022

CLAIM PROCESSOR

Mediassist India TPA. Pvt Ltd
10.2017 - 02.2021

Bachelor of Arts -

Y.E Rangaishetty College, Pavagada

Diploma in Computer Applications (DCA) -

MICE

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Shivakumar S