Open to opportunities

VARGHESE K SHAJI

@varghesekshaji

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Senior Medical Officer specializing in cashless health insurance claims and ICD/PCS-compliant medical record auditing.

India

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What I'm looking for

I’m looking for a role in health insurance operations where I can handle cashless pre-authorization and claims auditing end-to-end, ensure ICD/PCS and IRDAI compliance, and partner with providers to improve accuracy, turnaround time, and policyholder outcomes.

I’m a licensed Ayurvedic Physician with specialized, results-driven experience in health insurance operations—especially cashless pre-authorization and claims auditing. I audit complex medical records, verify diagnosis alignment using ICD & PCS coding standards, and ensure strict compliance with IRDAI regulations.

I manage the end-to-end cashless claims workflow from initial receipt to final resolution, consistently meeting internal turnaround time (TAT) metrics. I routinely process 65+ high-volume claims daily, and collaborate directly with healthcare providers and hospital management to resolve claim disputes and reduce financial burden on policyholders.

Alongside insurance operations, I deliver strong clinical practice and patient-centered care. I’ve served in roles including Senior House Surgeon and Consulting Doctor, leading outpatient assessments, treatment planning, documentation, follow-ups, and community health initiatives like medical camps and vaccination support.

Experience

Work history, roles, and key accomplishments

Current

Consulting Doctor

Current

Sahyadri Ayurveda Clinic

Jul 2022 - Present (3 years 11 months)

Conduct personalized Ayurvedic consultations with diagnostic assessments and root-cause analysis for chronic and acute conditions. Formulated individualized therapeutic regimens using herbal remedies, dietary modifications, and preventative lifestyle guidance, and tracked treatment efficacy through long-term follow-ups.

Ayurvedic Consultation Assessments Root Cause Analysis Herbal Remedy Integration Diet Modification Chronic Care Management Clinical Case Management

Senior Medical Officer

Vidal Health TPA

Jan 2022 - Feb 2026 (4 years 1 month)

Managed end-to-end cashless pre-authorization and health insurance claims from receipt through final resolution. Audited complex medical records using ICD/PCS coding to ensure compliance with policy terms and IRDAI regulations, processing 65+ claims daily while consistently meeting internal turnaround time (TAT) metrics.

Cashless Pre Authorization Health Insurance Claims Claims Auditing IRDAI Compliance Medical Utilization Review

Senior House Surgeon

Govt Ayurvedic Dispensary

May 2023 - Nov 2023 (6 months)

Delivered comprehensive outpatient Ayurvedic healthcare, including patient assessments, clinical diagnoses, and customized treatment planning. Performed clinical procedures and maintained complete case documentation with monitoring and follow-ups, while also organizing community health camps and public yoga sessions.

Ayurvedic Outpatient Care patient assessment Ayurvedic Diagnosis Treatment Planning Case Documentation Community Health Camps Public Yoga Facilitation

COVID Doctor

BBMP

Jul 2021 - Nov 2021 (4 months)

Provided frontline COVID care with diagnosis and evidence-based treatment while supporting operational public health activities. Coordinated localized health surveys and vaccination camps, and helped ensure execution of pandemic containment and patient safety protocols.

COVID 19 Frontline Care Diagnosis Support Patient Safety Infection Control

Education

Degrees, certifications, and relevant coursework

Alva's Ayurvedic Medical College

Bachelor of Ayurvedic Medicine and Surgery, Ayurvedic Medicine and Surgery

2015 - 2021

Completed BAMS (Bachelor of Ayurvedic Medicine and Surgery) at Alva's Ayurvedic Medical College under Rajiv Gandhi University of Health Sciences from September 2015 to April 2021.