Shivani Modi

• Evaluate and determine general insurance claims eligible for resolution with 80% accuracy.
• Lead team building and development initiatives for team of 10+ members.
  Manage MIS and collate data for analytics purposes.
• Facilitate project planning meetings with team.
• Review approximately 50+ claims per day with attention to detail.
• Analysis of policy details, including coverage limits, exclusions, and eligibility criteria, to determine benefits available to policyholders.
• Interact with partners & clients via webinars and training.
• Engage and manage relationships with clients and stakeholders.
  Accountable for providing customers with information prior to ombudsman hearings.
• Generate content for insurance-related blogs.
  Improved team efficiency by streamlining processes and implementing innovative management strategies.
• Identified areas for improvement within department, implementing strategic initiatives to address gaps in performance or resources.

• Utilized business analysis for detecting various forms of insurance fraudulent activities.
• Identified instances of financial loss within payment procedures.
• Implemented strategies for improving investigation efficiency and ensuring timely claim closure.
• Validated and processed medical claims with meticulous attention to detail.
• Achievements: Raised recovery of approximately 17,122 USD against fraudulent claims and blacklisted 150+ hospitals involved in malpractice.
• Awarded "Pinnacle Winner" for outstanding performance.
• Managed cross-functional teams for successful project completion, resulting in enhanced company performance.

FCU Surveillance:

• Conducted retrospective analysis of claims and implemented remedial actions
• Reduced gaps between Claims Processing and Investigation teams through monthly claim audits
• Identified inaccuracies in initial processes and implemented corrective measures
• Achievements: Raised recovery of approximately 83,802 USD for wrongly settled claims and de-empaneled/blacklisted 110+ hospitals involved in malpractices

FCU Investigation:

• Conducted online and offline investigations of claims in North-East India, covering 19 states
• Reviewed claims in timely manner and met turnaround time for closure
• Investigated over 6,500 claims and identified fraudulent activities, resulting in savings of approximately 1,74,024 USD
• Ensured effective collaboration between investigators and company.
• Achieved departmental goals by developing and executing strategic plans and performance metrics.
• Awarded as "Pinnacle winner - Achiever of quarter" for outstanding performance

• Managed team of 70 kiosk operators and facilitated collaboration with hospitals
• Ensured prompt payment of claims and managed grievances through DGRC meetings
• Managed provider empanelment as per government guidelines
• Conducted monthly training sessions and provided education on fraud prevention
• Prevented fraudulent activities through surprise audits, suggestions for non-compliance, and disciplinary actions against confirmed cases of fraud
• Conducted interviews and hiring process for kiosk operators.