DR.ARPIT ABHISHEK SHAH
Ghaziabad,Uttar Pradesh
Summary
Healthcare and insurance professional with extensive experience in clinical care, hospital operations, and TPA management. Successfully leads high-value insurance operations, enhancing stakeholder relations and patient experiences through effective grievance resolution and claims management.
Overview
17
17
years of professional experience
Work History
Head, Hospital TPA & Insurance Operations
JEENA SIKHO LIFECARE LIMITED
Meerut ,Shuddhigram, Uttar Pradesh
07.2024 - Current
- Lead end-to-end hospital TPA and insurance operations with responsibility for 5+ crore of insurance business per month.
- Managed insurer and TPA relationships, facilitating resolution of claims, approvals, documentation, and escalation-related issues to enhance operational efficiency.
- Oversaw cashless processes, claims coordination, documentation, insurer/TPA communication, and operational workflows to ensure seamless service delivery.
- Coordinate clinical, billing, insurance, administration and patient-care teams for timely approvals, service delivery and revenue realization.
- Monitor insurance business performance, claim status, documentation and workflow efficiency; identify bottlenecks and drive process improvements.
- Led team members in insurance and TPA activities, prioritizing patient experience, compliance, and business performance.
Deputy Manager, Claims
NIVA BUPA HEALTH INSURANCE COMPANY
12.2023 - 07.2024
- Achieved recognition for managing more than 90% HNI cashless processing within the prescribed 30-minute TAT.
- Managed cashless preauthorization with 30-minute turnaround time and monitored cashless claim TAT to ensure timely processing.
- Resolved grievances related to denied cashless and reimbursement claims, enhancing customer satisfaction.
- Handled case management and tariff negotiation with healthcare providers across India.
- Executed fraud claim analysis and risk management initiatives across PAN India to mitigate risks.
Senior Consultant
Panchattva Ayurvedic Restoration Centre
04.2019 - 11.2023
Medical Officer
M.S. Ramaiah Ayurvedic Hospital
06.2018 - 03.2019
Assistant Manager, Claims
UNIVERSAL SOMPO GENERAL INSURANCE
08.2015 - 07.2018
- Led internal and external claim audits for TPA and in-house claims processes.
- Oversaw reimbursement claim adjudication for TPA and insurance company cases, ensuring compliance and accuracy.
- Conducted case management, grievance management, and fraud claim risk analysis across PAN India to mitigate losses.
- Cultivated corporate/client relationships with major corporates, including JITO, Musachi, and Systopic, enhancing service delivery.
- Actively contributed to SOP and UAT development.
- Participated in product development and medical underwriting.
Assistant Manager, Claims (Medical Risk Management)
MAX BUPA HEALTH INSURANCE
03.2014 - 07.2015
- Coordinated case management and negotiated tariffs with providers across India to optimize reimbursement processes.
- Facilitated cashless preauthorization within 30-minute TAT, ensuring efficient claim workflows.
- Resolved grievances related to denied cashless and reimbursement claims, enhancing customer satisfaction.
- Performed fraud claim analysis and risk management across PAN India.
Senior Medical Officer
PARAMOUNT HEALTH SERVICES (TPA)
10.2013 - 03.2014
- Evaluated reimbursement claims for accuracy and compliance.
- Processed cashless claims and authorized preauthorization requests.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Completed day-to-day duties accurately and efficiently.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Medical Officer
City Central Hospital
Ghaziabad
03.2011 - 05.2013
Medical Officer
Combined District Hospital
Ghaziabad
04.2009 - 01.2011
Education
Bachelor of Ayurvedic Medicine & Surgery (BAMS) -
Indian Institute of Ayurvedic Medicine & Research
Bangalore01-2009
Post-Graduation - Human Rights
Indian Institute of Human Rights
New DelhiPGDM - Marketing
IMT-CDL
GhaziabadDiploma - Health Insurance
Insurance Institute of India
Skills
- Health insurance operations
- Cashless Preauthorization
- Reimbursement Claims Adjudication
- Medical Claims Review
- Claims Audit
- Fraud analysis
- Grievance management
- Case Management
- Tariff Negotiation
- Provider relationship management
- Hospital Operations
- Healthcare Revenue Monitoring
- Product Development
- Medical Underwriting
- Process development
- Team Management
- Customer Experience
- Microsoft Excel & Word
Personal Information
Title: Senior Healthcare Professional | Hospital Operations | TPA & Health Insurance | Ayurveda & Panchakarma
LANGUAGES
Hindi – Fluent, English – Professional Working Proficiency, Bengali – Working Proficiency, Kannada
Accomplishments
- 17+ years of professional experience across healthcare, Ayurveda, Panchakarma, insurance and hospital operations.
- 5+ crore insurance business managed per month in current hospital TPA & insurance function.
- More than 5 years of health-insurance/TPA experience in cashless preauthorization and reimbursement claims.
- Strong expertise in claim adjudication, case management, grievance redressal, fraud/risk management and stakeholder coordination.
Timeline
Head, Hospital TPA & Insurance Operations
JEENA SIKHO LIFECARE LIMITED
07.2024 - Current
Deputy Manager, Claims
NIVA BUPA HEALTH INSURANCE COMPANY
12.2023 - 07.2024
Senior Consultant
Panchattva Ayurvedic Restoration Centre
04.2019 - 11.2023
Medical Officer
M.S. Ramaiah Ayurvedic Hospital
06.2018 - 03.2019
Assistant Manager, Claims
UNIVERSAL SOMPO GENERAL INSURANCE
08.2015 - 07.2018
Assistant Manager, Claims (Medical Risk Management)
MAX BUPA HEALTH INSURANCE
03.2014 - 07.2015
Senior Medical Officer
PARAMOUNT HEALTH SERVICES (TPA)
10.2013 - 03.2014
Medical Officer
City Central Hospital
03.2011 - 05.2013
Medical Officer
Combined District Hospital
04.2009 - 01.2011
Bachelor of Ayurvedic Medicine & Surgery (BAMS) -
Indian Institute of Ayurvedic Medicine & Research
Post-Graduation - Human Rights
Indian Institute of Human Rights
PGDM - Marketing
IMT-CDL
Diploma - Health Insurance
Insurance Institute of India