Swarnalatha

Results-driven Healthcare Claim Adjudicator with 3+ years of progressive experience in end-to-end claims processing, adjudication, and quality assurance. Expert in ICD-10-CM, CPT, HCPCS Level II coding, Coordination of Benefits (COB), denial management, and HIPAA/CMS compliance. Proven track record of 100% quality accuracy, team mentorship, and complex claim resolution aligned with HCSC standards.

Senior Process Executive – Healthcare Claims - Cognizant Technology Solutions

(2024-01)

• Adjudicated high-complexity medical and institutional claims by applying payer-specific contract terms, plan benefit structures, and CMS/HIPAA regulatory guidelines — ensuring full compliance and reducing claim error rates across the team.
• Led resolution of escalated claim disputes including denied, pended, and incorrectly processed claims through detailed EOB analysis, COB rule application, and coordination with clinical and provider relations teams, achieving faster turnaround and improved first-pass resolution.
• Served as the subject matter expert (SME) for Coordination of Benefits (COB), accurately determining primary vs. secondary payer liability across commercial, Medicare, and Medicaid plans and guiding team members on complex multi-payer scenarios.
• Mentored and trained new hires on end-to-end claim adjudication workflows, ICD-10-CM/CPT/HCPCS coding validation, system tools, and compliance policies — cultivating a high-performing team with consistent quality and productivity benchmarks.
• Orchestrated quality audits and monitored team KPIs including accuracy rate, productivity, and turnaround time (TAT); identified root causes of processing errors and implemented corrective action plans that significantly improved team performance metrics.

Process Executive – Healthcare Claims - Cognizant Technology Solutions

(2023-01 - 2024-01)

• Executed end-to-end adjudication of high-volume medical claims — verifying member eligibility, plan benefits, deductibles, copays, coinsurance, and out-of-pocket maximums — while consistently achieving 100% quality accuracy within established turnaround timeframes.
• Applied Coordination of Benefits (COB) rules to accurately process claims involving multiple payers, determined correct reimbursement amounts, and validated ICD-10-CM diagnosis codes, CPT procedure codes, and HCPCS Level II codes for billing compliance and medical necessity.
• Reviewed and interpreted Explanation of Benefits (EOBs) and remittance advices to detect and resolve claim discrepancies, underpayments, and overpayments — flagging potential billing irregularities and escalating fraud/abuse indicators to the compliance team.
• Maintained HIPAA-compliant documentation of all claim decisions, audit trails, and resolution records, ensuring full traceability and regulatory readiness for internal and external audits.
• Identified process inefficiencies contributing to backlogs and collaborated with team leads to implement workflow improvements — reducing processing delays and directly contributing to measurable gains in individual and team productivity targets.

B.Com - Professional Accounting - Sankara College of Science and Commerce (2019-01 - 2022-01)

HSC - Government Higher Secondary School (2018-01 - 2019-01)