Sai Deepika

Results-driven Healthcare Team Lead and Lean Six Sigma Black Belt Certified professional with 7+ years of U.S. healthcare experience in Quality Assurance, claims adjudication, RRR (Retro review recovery), healthcare compliance, and team management. Proven record of maintaining 99%+ quality scores, improving efficiency, reducing errors, and meeting productivity and SLA targets. Expertise in Authorization, Medicare, Medicaid, Commercial Claims, CMS guidelines, Provider Services, Account Management, Care Navigation, Appeals, RCA, HIPAA compliance, and audit workflows.

Skilled in data analysis, process improvement, compliance, stakeholder management, cross-functional collaboration, CAPA, and team mentoring to drive quality and measurable business outcomes.

Team Lead - AMPS Healthcare - Hyderabad

(2021-12)

Lead Quality Assurance operations supporting U.S. healthcare advocacy, claims, account management, and related healthcare workflows, maintaining 99%+ quality performance.

• Manage team productivity, workload allocation, attendance, quality performance, and SLA adherence to ensure operational targets are achieved.
• Conduct regular quality reviews, coaching sessions, feedback discussions, and performance monitoring to improve individual and team performance.
• Perform Root Cause Analysis (RCA) to identify process gaps, knowledge gaps, and recurring quality issues.
• Apply Lean Six Sigma methodologies, including DMAIC, 5 Whys, Fishbone Analysis, Pareto Analysis, and PDCA, to address process defects and improve quality.
• Develop and implement Corrective and Preventive Actions (CAPA) based on audit findings and recurring error trends.
• Analyze quality data and audit trends to identify operational risks, recurring defects, and opportunities for process improvement.
• Prepare quality reports and provide actionable insights to leadership to support business and operational decisions.
• Collaborate with operations, leadership, and cross-functional teams to resolve complex issues and improve process performance.
• Ensure adherence to HIPAA requirements, client guidelines, SOPs, and healthcare compliance standards.
• Coach and mentor analysts on healthcare workflows, quality standards, process requirements, and compliance.
• Support process documentation, SOP updates, quality calibration, and workflow standardization.
• Support high-priority RRR and Advocacy-related operations, balancing audit requirements with business-critical workloads.
• Contribute to process automation and improvement initiatives designed to reduce manual effort and improve operational efficiency.

Senior Quality Analyst - AGS Healthcare - Hyderabad

(2021-02 - 2021-11)

Conducted detailed quality audits across U.S. healthcare claims, advocacy, and account management processes, consistently achieving 99%+ quality accuracy.

• Reviewed transactions and accounts for process adherence, documentation accuracy, compliance, and correct workflow execution.
• Identified critical, major, and minor quality defects and communicated findings to operations teams.
• Performed RCA for recurring and high-impact errors and recommended corrective actions.
• Used DMAIC, Pareto Analysis, Fishbone Diagram, 5 Whys, and PDCA to investigate and resolve recurring process issues.
• Implemented and monitored CAPA activities to prevent recurrence of identified quality issues.
• Prepared quality reports, audit summaries, and trend analyses for leadership.
• Provided actionable feedback and coaching to analysts based on audit findings.
• Collaborated with Team Leads and Operations to address quality gaps and improve process adherence.
• Supported quality calibration and standardization activities to ensure consistent interpretation of process requirements.
• Reviewed SOPs and process documentation and identified opportunities for improvement.

Associate - AGS Healthcare - Hyderabad

(2021-02 - 2021-11)

• Monitored and applied CMS policies, NCDs, LCDs, Medicare guidelines, and payer-specific requirements to ensure claims processing accuracy and compliance.
• Interpreted healthcare reimbursement policies and translated regulatory requirements into actionable claims validation criteria.
• Performed detailed analysis of claims edits, EOBs, denials, reimbursement patterns, and payment discrepancies.
• Reviewed first- and second-level appeal responses to validate permitted payment levels before provider submission.
• Conducted Root Cause Analysis of incorrect adjudications, payment discrepancies, and claims-processing errors.
• Executed end-to-end validation and testing of claims workflows, including complex and edge-case scenarios.
• Performed line-level claim analysis to verify pricing accuracy using Medicare rates and reference-based pricing methodologies.
• Developed and maintained SOPs and process documentation to ensure consistent claims validation and compliance.
• Acted as a Subject Matter Expert (SME) for claims adjudication, coding practices, reimbursement policies, and healthcare workflows.
• Trained and mentored team members on claims processes, healthcare policies, coding practices, and quality standards.

Process Associate - AGS Healthcare - Hyderabad

(2021-02 - 2021-11)

• Reviewed and processed U.S. healthcare provider claims, including pending and unpaid claims.
• Analyzed claim denials and billing discrepancies to determine appropriate resolution actions.
• Performed accounts receivable activities to support timely and accurate reimbursement.
• Maintained accurate accounts receivable records and payment documentation.
• Reviewed claims for compliance with payer-specific requirements and healthcare billing standards.
• Collaborated with internal teams to resolve complex claim issues and improve payment recovery.
• Maintained productivity and quality standards while handling high-volume healthcare claims.

Associate - Sutherland Healthcare - Hyderabad

(2019-04 - 2020-12)

• Processed and resolved U.S. healthcare claim denials and accounts receivable for healthcare providers.
• Analyzed denial trends and identified appropriate actions to improve claim resolution and payment recovery.
• Applied CPT, ICD-10-CM, HCPCS, modifiers, and Place of Service (POS) codes during claims processing.
• Reviewed healthcare claims for accuracy, completeness, and compliance with payer requirements.
• Managed high-volume workloads while maintaining quality and productivity targets.
• Mentored and trained new team members on claims processing procedures and quality standards.
• Collaborated with team members to resolve complex claims and meet operational SLAs.

B.tech - Computer Science & Engineering - Sir C. R. Reddy College of Engineering (2014 - 2018)