Utkarsh Rai

Dynamic healthcare operations professional with a proven track record in US healthcare claim adjudication, specializing in resolving provider and member grievances through detailed research of plan concepts such as deductibles, co-pays, and out-of-pocket variations. Exceptional ability to manage complex medical claims with precision, consistently achieving high accuracy and meeting stringent Turnaround Time (TAT) targets within a global delivery framework. Experienced as an Appeals Representative Associate at Optum Global Solutions, leveraging analytical skills to enhance operational efficiency and client satisfaction.

Committed to driving process improvements and delivering results in fast-paced environments.

Appeals Representative Associate at Optum Global Solutions (2025-01 – Present)

Healthcare operations professional specializing in US healthcare claim adjudication and appeals resolution

• Regulatory Compliance: Ensure all appeals are processed within mandated timelines (TAT) to comply with ERISA, CMS, or state regulatory standards, avoiding penalties, and ensuring member satisfaction
• Root Cause Analysis: Conduct deep-dive research into claim denials by navigating internal platforms (e.g., Facets, NDB and Citrix) to identify and resolve systemic billing or coding errors
• Professional Communication: Draft clear, concise, and professional appeal determination letters for members and providers, explaining complex medical and financial decisions in an accessible manner
• Quality Standards: Actively participate in coaching and feedback sessions to align with global quality standards, maintaining an audit accuracy score of 99.99%
• Cross-Functional Collaboration: Partnered with diverse teams to ensure proper handling of complex cases, leading to more accurate claim outcomes
• Data Integrity: Managed sensitive client information with high levels of confidentiality and discretion, maintaining trust between customers and the organization

Bachelor of Commerce in Commerce – Shibli National College (2022-06 – 2024-06)

12th in Commerce – St.Xavier's High School (2020-03 – 2021-03)

10th – St.Xavier's High School (2017-03 – 2019-03)