Vishal Uplekar

Results-driven Health Insurance Claims Adjudicator with 4+ years of experience in the US healthcare domain. Demonstrated expertise in reviewing, processing, and adjudicating high-volume medical claims in compliance with payer policies, regulatory guidelines, and contractual terms. Proven track record of maintaining high accuracy and efficiency while delivering excellent service across complex claims scenarios including 837 EDI transactions, production support, and multi-system environments.

Knowledge Specialist - Mphasis

(2024-07)

• Adjudicate complex US health insurance claims with high accuracy, ensuring compliance with payer policies, CMS guidelines, and contractual terms.
• Serve as a knowledge resource for the claims team, assisting with complex claim scenarios, escalations, and policy interpretation.
• Collaborate with cross-functional teams to streamline claims workflows and reduce processing turnaround time.
• Maintain quality benchmarks while managing a high volume of professional and institutional claims (CMS1500 / UB-04 formats).
• Utilize ServiceNow ticketing system to track, manage, and resolve claims-related issues and production incidents.

Associate – Claims Processing - EXL Services

(2023-09 - 2024-07)

• Processed and adjudicated health insurance claims, verifying eligibility, coverage, and medical necessity in accordance with plan benefits.
• Reviewed and denied claims that did not meet coverage criteria, documenting decision rationale with proper denial codes (CARC/RARC).
• Requested missing documentation from insured members and providers to facilitate accurate and timely claim resolution.
• Consistently met daily productivity and quality targets in a fast-paced, high-volume claims processing environment.
• Gained hands-on exposure to life insurance claims processing by independently managing a life insurance project for 6 months, handling policy verification, claims intake, and end-to-end processing workflows.

Associate KPO – Claims Adjudicator (Production Support) - Atos

(2021-12 - 2023-05)

• Served as part of the 837 EDI support team, providing application support for the Edifice platform in a production environment.
• Monitored application logs, identified errors, and resolved claim edit errors, transaction rejections, and payer-specific edits in the 837 claim transaction sets.
• Managed file operations by putting files on run, monitored system performance, and ensured timely data processing.
• Executed scheduled SSIS jobs every Saturday for batch data processing, ensuring accuracy and completion of weekly data workflows.
• Monitored FTP servers for inbound and outbound claim file transmissions, ensuring timely and accurate data exchange.
• Managed low and medium priority incident tickets using the service management application, ensuring timely resolution and documentation.
• Supported production stability by proactively identifying issues, escalating incidents, and contributing to root cause analysis.

B.Sc. - Computer Science & Technology - Punyashlok Ahilyadevi Holkar Solapur University (2018)

HSC - Maharashtra State Board (2015)

SSC - Maharashtra State Board (2013)