Claims Adjudication Specialist | Grievance & Appeals (G&A) | Quality Analyst (IQT) - Carelon Global solutions
(2020-01 - 2026-12)
- Claims Adjudication & Processing: Expertly adjudicated complex Inpatient, Surgery, and Pended claims for Medicare (Parts A, B, C, D) and Medicaid lines of business, ensuring strict adherence to CMS and policy guidelines.
- System Proficiency: Navigated multiple healthcare applications including Blue Square, ACMP, FileNet, E-pact, Member360, and CI&W to verify eligibility, benefits, and prior-authorization status.
- Prior-Authorization & ROI: Evaluated Pre/Prior Authorization requests and managed Release of Information (ROI) by reviewing patient medical records while maintaining 100% HIPAA compliance and PHI security.
- Grievance & Appeals (G&A): Analyzed and resolved provider/member complaints and grievances, providing timely solutions to enhance provider satisfaction and meet service-level agreements (SLAs).
- Quality Assurance & Audit: Conducted detailed audits of processed claims to identify discrepancies, ensuring high accuracy levels and identifying Medicare coverage trends through data analysis.
- Leadership & Training: Served as a Subject Matter Expert (SME), coaching and training new and existing employees on investigative case types, internal control processes, and medical record review.
- Strategic Coordination: Collaborated with cross-functional departments during business transitions and informed applicants of relevant agency assistance to streamline implementation.
Senior Process executive - Cognizant Solution Technology
(2016-01 - 2019-11)
- FACETS Administration & Processing: Managed end-to-end processing of Large Group and Small Group applications using the FACETS application, ensuring 100% data integrity for billing.
- Data Validation & Analysis: Acted as a Healthcare Data Analyst, screening and validating client information to ensure completeness and accuracy before final submission.
- Case Management: Utilized internal databases to record, track, and monitor incoming cases, maintaining a streamlined workflow for high-volume data processing.
- Quality Auditing: Performed rigorous audits of case information after internal submission to identify gaps and ensure high-quality deliverables to the client.
- Stakeholder Communication: Identified and collected missing information by coordinating with external agents and internal clients via professional email communication.
- SME & Training: Served as a FACETS Trainer, onboarding freshers and providing troubleshooting support for complex case studies and technical issues.
