Komal Sharma

Detail-oriented Quality Control Analyst – US Healthcare with 9+ years of relevant experience, including strong expertise in healthcare claims validation, quality assurance, and process improvement. Experienced in handling end-to-end claims review healthcare audits, and high-value claims analysis in fast-paced healthcare environments. Skilled in identifying discrepancies, ensuring compliance with payer and CMS guidelines, and improving process accuracy through root cause analysis.

Proven track record of maintaining 99%+ quality standards in high-volume and deadline-driven environments.

Quality Control Analyst – US Healthcare - Carelon Global Solutions

(2020-01)

• Performed end-to-end US healthcare claims validation and quality review, ensuring compliance with payer and CMS guidelines
• Audited high-dollar US healthcare claims (Non-ITS & ITS) exceeding $40K using Pega CIW, ensuring accurate post-audit release
• Conducted detailed claims audits covering eligibility, duplication, authorization, benefits, pricing, and coding validations
• Identified procedural and financial discrepancies, raised notifications through SharePoint, and coordinated resolutions with stakeholders through IQTs
• Collaborated with onshore and offshore teams to identify process gaps and improve overall audit quality and workflow efficiency
• Conducted root cause analysis (RCA) to identify process gaps and improve overall quality accuracy
• Collaborated with cross-functional teams (operations) for issue resolution and process improvements
• Worked on Pega CIW and DEX (Digital Examiner Tool) to validate automated claims workflows and audit outcomes
• Maintained 99%+ quality accuracy and contributed to process enhancements and audit documentation
• Worked extensively on Pega CIW, DEX (Digital Examiner Tool), SharePoint, Excel trackers, and mainframes for claims validation and audit workflow management

Customer Service Manager – Claims - ICICI Lombard General Insurance Co. Ltd.

(2016-08 - 2019-11)

• Managed end-to-end claims processing for Personal Accident and corporate policies
• Ensured accurate documentation and timely claim settlement
• Handled escalations and provided resolution for complex claim issues
• Coordinated with internal teams for smooth claim adjudication
• Trained new team members on claims processing and compliance

Accounting Executive - Gilda Industries

(2008-12 - 2016-08)

• Managed journal entries, ledger posting, and account reconciliation
• Assisted in financial reporting and year-end closing activities
• Ensured accuracy and compliance in accounting records

M.Com - Acharya Nagarjuna University (2007)

B.Com - Acharya Nagarjuna University (2005)