Gopinath Gorantla

Healthcare Data Analyst with 9+ years of experience working across healthcare data, Medicaid programs, claims, and revenue cycle operations. Strong background in analyzing claims, eligibility, provider, encounter, utilization, and payment data to support accurate reporting and better business decisions. Experienced with SQL, Snowflake, Power BI, and Tableau, along with hands-on knowledge of MMIS, HEDIS, risk adjustment, claims adjudication, CMS reporting, FHIR, HL7, REST APIs, Postman, and data validation.

Combines a solid understanding of healthcare operations with practical data analysis and healthcare data exchange experience to help clinical, payer, and leadership teams understand what the data is showing and where action is needed.

Healthcare Data Analyst at Molina Health Care (2026-01 – Present)

• Analyzed claims, eligibility, provider, and clinical encounter data using SQL, improving data accuracy by 18% across large multi-state healthcare datasets.
• Built Power BI and Tableau dashboards to track HEDIS measures, healthcare utilization, readmissions, and risk-adjustment performance for clinical and payer operations teams.
• Reviewed medical cost and utilization trends using SQL and Snowflake, identifying 9% cost variances across specialty pharmacy and outpatient services.
• Standardized data validation and reconciliation processes for claims and provider records, reducing reporting discrepancies by 22% and supporting accurate CMS and Medicaid reporting.
• Partnered with clinical, finance, and operations teams to validate healthcare data exchanged through REST APIs, FHIR resources, and HL7 interfaces, using Postman to test responses and troubleshoot data issues.

Data Analyst – Medicaid MMIS Modernization at State of Illinois (2023-12 – 2025-11)

• Used SQL to transform, merge, and filter more than two million Medicaid records across claims, eligibility, provider, encounter, and payment data during a Teradata-to-Oracle Cloud MMIS modernization.
• Served as a subject matter resource on MMIS data structures, supporting claims intake and adjudication, eligibility and enrollment, provider master data, managed care encounters, and 835 remittance transactions.
• Validated ETL mappings, source-to-target transformations, and adjudication rules across claims, eligibility, provider, and payment records to ensure data accuracy and CMS compliance.
• Built and maintained validation reports and reconciliation tracking to monitor the accuracy and completeness of Medicaid Data Warehouse submissions.
• Coordinated with state Medicaid staff, ETL vendors, and QA teams to resolve more than 120 Sev-1 and Sev-2 defects with regulatory or financial exposure, supporting continuity throughout the system transition.
• Produced audit-ready reconciliation packages and variance reports for CMS review while maintaining HIPAA, PHI, and PII compliance throughout the modernization effort.

Subject Matter Expert – Revenue Cycle Analytics at Promantra Synergy Solutions (2019-05 – 2022-04)

• Led a team handling OBGYN professional claims submitted on CMS-1500 forms, serving as the main point of contact for escalations, productivity tracking, and day-to-day revenue cycle issues.
• Implemented a structured appeals process by reviewing denial trends across coding errors, missing documentation, and pre-authorization issues, helping improve first-pass resolution and reduce repeat denials.
• Managed complex denial escalations with billing, coding, and payment posting teams, resolving documentation gaps and preparing cases for timely appeal submission.
• Monitored a $500K+ outstanding claims portfolio, reviewing payer trends, high-value denials, and recovery opportunities across Medicare, Medicaid, and commercial accounts.
• Built Power BI dashboards and Excel-based reconciliation, variance, and aging reports to give leadership a clearer view of denial trends, AR performance, and revenue recovery.
• Coached team members on productivity, payer policy updates, and performance improvement plans while coordinating with Workforce Management and Capacity Planning to meet daily workload targets.

Process Lead – Healthcare Claims Operations at Medico Healthcare Services (2017-03 – 2019-05)

• Progressed from Senior Associate to Process Lead, driving process improvements that increased efficiency and reflected a consistent, initiative-taking approach to workflow enhancement.
• Managed daily claims operations across multiple physician specialties - Physical Therapy, DME, Psychiatric Services, Internal Medicine — overseeing team resources and workflow allocation to meet assigned targets.
• Resolved high-dollar aged AR accounts (180+ days), driving significant cash collections on outstanding balances.
• Led a special project with Molina Healthcare resolving 3,500 incorrectly denied claims tied to provider contract issues, coordinating with credentialing and claims teams to recover $155K–$170K in payments.
• Managed CPT fee schedule disputes for UHC health plans, partnering with medical coding teams to identify contract fee gaps and reprocess claims for accurate reimbursement.
• Led automation efforts to segregate newly submitted claims, partnering with IT to build tools that reduced manual workload and follow-ups by 15–25%.

Revenue Cycle Associate at Elico Healthcare Solutions (2015-08 – 2017-03)

• Supported denial tracking, appeals documentation, and payer follow-ups for Medicare, Medicaid, and commercial portfolios.
• Analyzed aging AR over 365 days across Medicare, Medicaid, and commercial payers, identifying denial patterns, revenue leakage, and recovery opportunities for stakeholder reporting.
• Reviewed provider-related remittance advice and documentation to identify discrepancies.
• Reviewed EOB/ERA data to identify underpayments and discrepancies, supporting payment integrity and recovery initiatives that helped recover an estimated $30K+ in missed payments under tight turnaround deadlines.
• Created and maintained Excel and Access-based reconciliation, variance, and aging dashboards for leadership visibility and program monitoring.
• Partnered with billing, coding, and compliance teams to gather documentation and ensure completeness and accuracy of reimbursement data.

Master of Science in Health Informatics – New England College (2022-05 – 2023-10)

Bachelor of Science in Biotechnology – RVR & JC College (2010-06 – 2014-09)