Health Insurance Claim Process Auditor
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Seeking Higher & Responsible position, which will enable me to apply my overall skill.
7 years of Claims processing and auditing experience in US healthcare industry.
1 year experience for eBay chat process. 1 year in UK Gas and utility process.
1 + Year experience as a Manager in Hospitality Industry. 1 year experience in Share Market.
Job Profile » Handling US, UK, Australia, Canada Dasher on Chat andCall. » Solving problem of Dasher related to Account, Payment, App, Card, Activation, reactivation, Program, Company inquiry, Scheduling, Sing up, Order etc. » Solving issue related to delivery. Order not pickup, Order not here. Order not Ready etc. » App issue, App basic troubleshoot steps, Navigation, » Helping dasher if customer do not respond. » Canceling order at the time of emergency, accident, order picked up by another dasher, item level issue etc. » Calling Merchant and helping the dasher to resolve their issue. » Calling Dasher and resolving their issue in a given timeframe. » Referring KB’s and Work Follow Tool (WTF) to resolve issue of Dasher.
» Logging case note and escalating the issue to concern department. » Coordinating with Team Leader, SME and higher management to resolve the case. Jan 2020 –June 2021 TTEC for eBay {Ahmadabad(WFH)} Customer Service Chat Rep (18 Months) Job Profile » Assisted customers with various inquiries; website, payment, shipping, policies, complaints, etc. » Provided accurate and appropriate inform action in response to customer inquiries. » Demonstrated mastery of customer service within specified time frames. » Documented trending issue. » » Made reasonable procedure exceptions to accommodate unusual customer requests. » Took special orders from supervisors for escalated customers. » Maintained up-to-date knowledge of site(s) policies, regarding payments, returns and exchanges. » Maintained stable performance metrics. » Managed quality communication, customer support and productre presentation.
Subject Matter expert: SME role. » Help team to resolve seller query within a time frame. » Encourage team to achieve there given target
Quality Specialist Auditor United Health Group(Hyderabad) (36 Months) Dec 2011 – Dec 2014 Job Profile » Handling health and accident claim audits for U.S process. »Determining of claim benefits based on Insured Health History&insurance plan.»Selecting correct hospitals & physicians for appropriate payment. »Communicating & liaising with the helpdesk &several other departments for different claim related queries. »Referring IBaag, medical dictionaries, SOP’s &certificate of coverage to determine the coverage of claims submitted by the provider. »Auditing overpayment/ underpayment adjustment, Medicare claims, » Other insurance co-ordination, duplicate claims, accidental claims&manual adjustment. » Follow HIPPA rules and regulations. » Expert in Over payment identification & recovery process through R-OV linecr» Expertise to understand Explanation of benefits(EOB) » Flowing Checklist for the auditing of claims. » Charge Error for wrong processing of claims in all parameters. » Auditing and Validating R-OV line for Overpaid claims, 30line and 20line adjustment for underpaid and overpaid claims. » ICD-9, ICD-10, Cause code, Diagnosis code, UB-04 Claims, HCFA-1500 Claim CPT Code and HCPCS Code. » Good knowledge on Medicaid and Medicare payment methodologies. » Expertise to understand payer contract to validate payments » Knowledge on resolving Duplicate claims, payer denials(Medicare, Medicaid&Other Insurance) » Using appropriate Remark Code while auditing the claims. » Calculating Copay, Deductibles, Coinsurance while auditing claims. » Resolving Edits and Warning while processing claims. » EDS-1 to EDS-10, EOB, Adjudication of Other Insurance claims, Medicare claims, Medicaid Claims, Inpatient Claims and Outpatient Claims.» Providing training on error charged on validation. » Following 5whys on error charged.
» Cleared Bachelor of Commerce in year 2005 - 2006 from University of Mumbai securing Pass Class. » Cleared HSC in year 2002 - 2003 from Mumbai Board securing IInd Class. » Cleared SSC in year 2000 - 2001 from Mumbai Board securing IInd Class.
