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Vaibhav Naik

@vaibhavnaik

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Experienced Medical Claim Assessor with expertise in healthcare management.

India

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What I'm looking for

I am looking for a role that allows me to leverage my expertise in claims assessment and quality management, while fostering a collaborative and growth-oriented work environment.

With over three years of experience in health insurance claim assessment and quality assurance, I have honed my skills in evaluating claims, conducting audits, and ensuring compliance with regulatory standards. My journey began with a Summer Internship at Future Generali India, where I developed a strong foundation in claims processing. I then advanced to the role of Assistant Manager at Manipal Cigna, where I successfully optimized processes and identified fraudulent billing patterns, saving the company significant resources.

Currently, I serve as the Manager for AB-PMJAY, where I lead hospital audits and coordinate with various stakeholders to enhance operational efficiency. My clinical background as a Resident Medical Officer has equipped me with a unique perspective on patient care and hospital operations, allowing me to streamline workflows and implement corrective actions effectively. I hold an MBA in Hospital & Healthcare Management and a BHMS degree, which further solidifies my expertise in this field.

Experience

Work history, roles, and key accomplishments

Manager – Medical & Quality Management

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY

Nov 2023 - Present (1 year 8 months)

Conducted guideline-based reviews of AB-PMJAY medical claims to approve or reject requests, ensuring regulatory compliance and accurate decision-making. Led hospital audits to evaluate adherence to quality protocols and operational standards.

Quality Management Regulatory Compliance

Assistant Manager – Claims Quality

Manipal Cigna Health Insurance

Jun 2022 - Present (3 years 1 month)

Assessed and evaluated insurance claims per legal and company guidelines, performing quality checks on TPA-submitted claims to ensure policy compliance. Identified fraudulent billing patterns, saving INR 2.75 Crore to date.

Claims Quality Assurance Fraud Detection Compliance Process Optimization

Resident Medical Officer

Trimurti General Hospital

Aug 2018 - Present (6 years 11 months)

Diagnosed and managed common disease conditions in emergency and ICU settings, administering treatment plans and medications under senior physician guidance. Coordinated with nurses, therapists, and technicians to deliver holistic patient care.

Emergency Medicine

Clinical Assistant

VM Salgaonkar's SMRC Hospital

Jan 2018 - Present (7 years 6 months)

Monitored patient vitals and conducted ward procedures according to protocols, ordering and documenting investigations and progress notes. Participated in hospital-wide quality improvement and safety initiatives.

Ward Procedures Quality Improvement Patient Safety

Clinical Assistant (On-call)

Siddhivinayak Healthcare Services

Dec 2016 - Present (8 years 7 months)

Assisted in employee health check-ups and pre-employment medical examinations, responding to 911 emergency calls to stabilize and treat patients on-site. Supported clinical procedures alongside senior physicians.

Education

Degrees, certifications, and relevant coursework

Symbiosis School for Online & Digital Learning

Diploma, Quality Management of Hospital & Healthcare Organization

Pursued a Diploma in Quality Management of Hospital & Healthcare Organization. Focused on understanding and implementing quality standards within healthcare settings.