Hemalatha D

Experienced US Healthcare professional with 8+ years of experience in Medical Claims Adjudication, Provider Contract Setup, Quality Assurance, and Healthcare Operations. Expertise in HCFA/UB claims processing, CPT/HCPCS/ICD coding validation, claims auditing, provider contract configuration, root cause analysis, and quality monitoring. Proven experience as Quality Analyst, Subject Matter Expert, and Internal Auditor with strong knowledge of payer policies, reimbursement methodologies, and healthcare compliance.

Proficient in Advanced Excel, reporting, process improvement, team coaching, and stakeholder management. Adept at driving quality initiatives, reducing defects, and improving operational efficiency in US healthcare environments.

Quality Analyst (US Insurance) at Firstsource (2023-02 – Present)

• Review processed medical claims to ensure they are adjudicated correctly
• Verify accuracy of CPT / HCPCS codes
• Verify accuracy of ICD diagnosis codes
• Verify accuracy of Modifiers
• Verify accuracy of Provider and member details
• Ensure claims follow payer policies and adjudication guidelines
• Identify processing errors such as incorrect denial
• Identify processing errors such as incorrect payment calculation
• Identify processing errors such as coding errors
• Identify processing errors such as eligibility verification mistakes
• Perform Root Cause Analysis (RCA) to understand why errors occurred
• Maintain audit scorecards for claim processors
• Track accuracy percentage, error trends, and defect rates
• Share quality reports with management and operations teams
• Provide constructive feedback to claim processors based on audit results
• Conduct one-on-one sessions to explain errors and corrective actions
• Identify process gaps and improvement opportunities
• Suggest changes to SOPs (Standard Operating Procedures)
• Work with operations teams to reduce recurring errors
• Assist during client audits or internal audits
• Provide documentation and analysis related to claim quality
• Participate in calibration sessions with clients and internal teams
• Maintain audit documentation and error logs
• Prepare daily, weekly, and monthly quality reports

Subject Matrix Expert at TCS (2022-09 – 2022-12)

• Resolving the Customer queries regarding the Credit card payments which is failed during transactions
• Team Handling
• Reports generations and assigning the task to the team members

Senior Process executive at Cognizant Technologize (2020-02 – 2022-09)

• Reviewing (IN Network) participating provider agreement and setup the Fee schedule in claim systems (CPF, Facets, Network Pricier) for auto adjudication process
• Based on provider specialty such as DME, SNF, Hospice, Therapy, Full Facility- Fee schedule will be created as per standard process guidelines
• Having knowledge about Rev Code, CPT/HCPC codes and reimbursement types
• Loading provider demographic information into claims system once Fee schedule is created
• To make sure Fee schedule is correctly tied up in all claims system in corresponding provider account and to make sure claims are billing correctly in the rate signed by provider/Payer

Transaction Processing Associate (US Healthcare) at Accenture Solutions (2018-07 – 2020-01)

• Experienced in Adjudicating both Medical / Hospital claims (HCFA / UB)
• Analyzing the claims based on guidelines and making decisions whether to Pay/Pend/Deny
• Knowledge of Corrected claims, Denials, Authorizations
• Expert in processing both EDI/Image claims
• Internal auditor and handle Defect analysis sessions to the team members
• Reviewing Participate provider Agreement and loading corresponding Codes (CPT, HCPC & Rev Codes) with rates based on Reimbursement type to get a claim priced correctly in Adjudication
• Providing support as internal auditor and providing KT to the associates to understand the concepts of process

Bachelor of English Literature in English Literature – KC Kasi Nadar College of Arts & Science (2014 – 2017)