Shaik Aslam

US healthcare payer operations professional with 4+ years of hands-on experience across claims processing, claims auditing, eligibility and benefits verification, prior authorization checks, denial analysis, payer policy validation, and CMS/HIPAA-compliant documentation. Experienced in production queue work for Commercial, Medicare, Medicaid, Managed Care, professional, and facility claim scenarios. Strong ability to explain real payer decision logic, including eligibility, benefit coverage, CPT/HCPCS alignment, authorization requirements, cost-share validation, duplicate/COB indicators, denial root causes, and escalation paths.

Pharmacy academic background with strong understanding of medical terminology, clinical documentation, and medical necessity concepts.

Senior Analyst - US Healthcare Benefits, Claims & Denial Review - Data Marshall

(2025-09 - 2026-02)

Project: Cypress

• Processed insurance eligibility and benefits verification work for physician and facility claim scenarios across Commercial and government payers.
• Verified coverage details including deductibles, copay, coinsurance, network status, plan exclusions, authorization requirements, and payer-specific benefit limits.
• Reviewed CPT, HCPCS, and J-code-related benefit requirements to support accurate claim handling, reimbursement validation, and denial prevention.
• Analyzed denied and underpaid claims, identified payer-policy or documentation gaps, and supported payer pushback using historical claim data and documented benefit evidence.
• Handled US payer calls to verify benefits, clarify authorization or coverage issues, and resolve claim-related discrepancies before closure.
• Maintained CMS/HIPAA-compliant documentation, SLA accuracy, audit notes, and exception tracking for high-volume production operations.

Senior Analyst - Claims Audit & Payer Compliance - Firstsource Solutions

(2024-08 - 2025-08)

Client: Cigna

• Audited Cigna commercial plan claims for eligibility, benefit limits, cost-share accuracy, authorization requirements, network status, coding accuracy, and payer policy alignment.
• Validated claim adjudication logic and identified where outputs diverged from expected payer rules, benefit documentation, or authorization requirements.
• Performed comprehensive reviews of professional and facility claims involving eligibility, medical necessity indicators, CPT/HCPCS alignment, and compliance requirements.
• Supported payer policy interpretation, benefit clarification, denial trend review, and corrective action to reduce rework and prevent avoidable denials.
• Participated in payer calls, escalations, audit reporting, internal calibration sessions, and quality feedback discussions to improve process consistency.
• Provided actionable feedback to associates and business leaders on claim discrepancies, root causes, process gaps, and quality improvement measures.

Claims Associate - Claims Processing & Benefit Validation - Carelon Global Solutions / Legato

(2022 - 2024)

Client: Anthem, USA

• Worked production claim queues for Anthem payer operations, reviewing insurance eligibility, benefit coverage, authorization/referral requirements, and payer-specific processing rules.
• Processed professional and facility claim scenarios involving Medicare, Medicaid, Managed Care, and Commercial payer benefits.
• Checked prior authorization, referral status, plan exclusions, member/provider details, CPT/HCPCS codes, and coverage rules before claim submission or escalation.
• Reviewed claim records to determine appropriate next action such as payable readiness, pending for information, denial risk, correction, rework, or escalation.
• Supported denial management by documenting eligibility mismatches, missing authorization, coding/benefit inconsistencies, duplicate indicators, and payer policy exceptions.
• Maintained accurate claim notes and documentation to support audits, payer reviews, SLA compliance, CMS expectations, and HIPAA standards.

Master of Pharmacy - Pharmacology - ANU, Guntur

Bachelor of Pharmacy - ANU, Guntur