Professional Summary:

Over * Years of substantial experience in Information Technology worked as Data Analyst and Medical billing Industry as a Claim Examiner / Refund check Adjuster/specialist

Wide experience in data entry and medical claim processing.

Expertise refund check processing, check request and invoices.

Initiated Payment recovery for overpayment.

Processed invoices payment and recorded information in account database

Profound knowledge of codes applicable in CPT, HCPC, Revenue and ICD-9 systems.

Investigating, negotiating, and resolving all types of appeals and grievances.

Good domain knowledge in FACET/OnBase application in medical billing, processing the claims and adjustments.

Communicating with appropriate parties, issues, implications, and decisions; analyzes and

identifies trends for appeals and grievances.

Demonstrated sound critical judgment, and decision-making skills.

Verifying medical claims verifying if medical claims paid calling providers to verify cpt codes for claims and appeals calling providers to verify claims submitted correctly verify tax id numbers

verifying providers and facilities.

Full-cycle medical claims processing (Pay, Pend, Deny) in health insurance industry

Facet configuration including medical plan, subscriber/member and claim processing application

Create claim test scenarios and clean up incorrect configuration

Responsible for processing personal inventory of claims to meet quota daily.

Crosstrained in the total loss with knowledge of determining the appropriate value, salvage and issuing settlement checks.

Facet Applications: Medical plan, Application support, Billing, claim processing provider, Prospective UM and Benefits review .

Gained technical expertise in Informatica PowerCenter 10.1.1/10.2, Oracle 12c/11g, SQL Server 2008R2/2012, Java Programming, Unix Shell Scripting and Linux/Windows.

Proficient in implementing complex business logic through Informatica PowerCenter transformations, Workflows/Worklets and Mappings.

Experience in creating complex mappings using various transformations, and developing strategies for Extraction, Transformation and Loading (ETL) mechanism by using Informatica 10.x/9.x

Implemented Data Integration with source and targets as Flat Files, Relational database, Oracle, SQL server, XML and CSV files.

Have implemented Slowly Changing Dimensions (SCD) type 1 and type 2 in data warehouse.

Worked on performance tunning of Informatica workflows by identifying performance bottleneck at the source, target and mapping level and taking appropriate actions to optimize the workflow.

Proficient in writing PL/SQL programming using Stored Procedures, Functions, Triggers.

Good experience in relational data modelling. Creating Indexes, analysing Index performance and optimizing query using SQL plan.

Working knowledge in development methodologies like Software Development Life Cycle (SDLC) processes, Agile, Scrum, Waterfall.

Successfully worked on multiple projects, working through different geographical time zones for Insurance and Retail domain clients.

Excellent communication, interpersonal skills, analytical skills, and strong ability to perform as a team player.

Technical Skills:

ETL Tools

Power Center 10.1.1/9.6.1

Database

SQL Server 2008R2/2012, Oracle 12c/11g

Programming

Java Programming

Languages/Scripting

SQL, PL/SQL, UNIX Shell Scripting, Windows Scripting

File Transfer/Encryption

(SFTP) secure file transfer

Scheduler

Informatica Scheduler, Windows Task Scheduler

Incident/Change Management

Service Now – Incident Management, Change Management, Paging Groups, Workgroup Management, Role Management

Operating Systems

Windows, LINUX

Education:

Bachelor of Engineering in Electronics and Communication – Anna University - India

Certifications:

Udemy Certified Informatica Expert Certification in Informatica PowerCenter 10

Udemy Certified SQL Server Expert Certification in SQL Server Database and PL/SQL

Udemy Certified Informatica Cloud -Data Integration (IICS)

Professional Experience:

Employer : First Source November 2022 - Present

Client : CareSource Insurance

Role : Claims Examiner/ Refund Specialist

Project : CareSource Professional claims

Location : Ohio, USA (Remote Position)

Refund Specialist (03/2023)

Facet /OnBase application tools

Timely and accurate processing and adjudication of all types of claims from assigned workflow queues.

Expertise refund check processing, check request and invoices.

Initiated Payment recovery for overpayment.

Processed invoices payment and recorded information in account database.

Investigated past due invoices and delinquent accounts to generate revenues and reduce number of unpaid and outstanding account.

Eliminated billing inaccuracies by reconciling accounts monthly.

Eliminated inaccuracies in account payable payment by verifying information prior to generating checks and electronic payment transfer.

Assisted in the training and development of new adjusters/refund specialist role.

Processed check requests, invoices, receipted and system recovered.

Balances all manual and electronic posted checks batches by generating the cash balancing.

Researched credit balance to determine if the refund was due to patient or the Insurance company.

Investigate among insurance companies to determines processed as primary or secondary.

Worked correspondence letter or cob details from insurance companies.

Ensure refund credits are issued to insurance providers and patients.

Claim Analyst II

Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications.

Having high productivity and quality standards within a claims processing automation environment

Troubleshooting of claim errors and resolving the pending error make process to payment

Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review.

Demonstrates a thorough knowledge of regulatory requirements, individual plan benefits, provider contracts, policies, and procedures for product assignment.

Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate.

Accurate and timely review of claim pricing to facilitate manual pricing as necessary, working with various Health Plan provider networks.

Good knowledge of Facets application and Facets claims processing.

Effectively communicate with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems.

Actively participated and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives.

Completed all mandatory compliance and corporate training

Environment: Facet application, Citrix, kronos applications, Medical billing, CRT tools

Employer : Cognizant Technology Solutions October 2015 - September 2016

Client : Woolworths (Australian Supermarket Chain)

Role : Informatica ETL Developer

Project : Supply chain management Data warehouse

Location : Chennai, India

Responsibilities:

As a developer, participated in implementing design, ETL testing, code development, creating test cases and performance tuning.

Worked on creating mappings, sessions, and workflows to meet complex business requirements and data migration.

Good understanding of ETL Concepts such as Extraction of data from various sources, transformation, and error check of data as per business logic and loading into multiple targets.

Involved in loading supply chain related data from fixed and delimited flat files from different source systems into the supply chain data warehouse.

Implemented SCD type 2 workflows for incoming data feeds into data warehouse to maintain history of records for reporting and analytics.

Participate in business and functional team meetings to gather requirements and define interface layouts for the projects

Define sources to target mappings and ETL designs for integration of new or modified data streams into the data warehouse and/or data marts

Validate the ETL design and ensure that technical specifications are complete, consistent, concise, and achievable

Create ETL mappings and workflows using Informatica PowerCenter and participate in ETL code review meetings to identify gaps in the ETL process

Provide performance tuning of the workflows wherever necessary and ensure ETL code and artifacts are properly versioned and stored in Visual Source Safe tool

Conduct ETL unit and integration testing with downstream systems to ensure data integrity across disparate systems

Create ETL deployment groups and participate in change review meeting for code deployment

Validate ETL code and data after deployment and ensure it meets business requirements

Environment: Informatica PowerCenter 9.6.1, Oracle 11g, SQL Server 2008, PL/SQL, Service Now

Employer : MiraMed Ajuba Global Services August 2013 – October 2015 Role : Medical Claim Processor

Project : MEDDATA

Location : Chennai, India

Responsibilities:

Wide experience in data entry and medical claim processing

Profound knowledge of codes applicable in CPT, HCPC, Revenue and ICD-9 systems.

Deep knowledge of Red Book, ASC Groupings, DRGs, Health Maintenance Organization (HMO) and IPA claim payments adjudication.

Familiarity about rules and regulations at DMHC and CMS.

Proficient in submission and editing claims electronically and other on-line systems for claim processing and problem registration

Skilled at decision-making, effective communication, analytical and research-oriented tasks.

Ability to process claims for surgery, radiology, lab and medicine for CMS 1500 and CMS 1450 claim forms

Engaged to input data into processing system after interpreting medical coding and knowing terminology used in medicine professions in respect to procedures and diagnoses.

Ensured to process assigned claim forms and inspect apt allocation of co-pays, deductibles, reimbursements and co-insurance.

Complied with all judgmental policies and processes to assure appropriate claim payments.

Provided excellent customer service to all providers, members, insurance companies and billing department.

Maintained written record of phone calls in system and adhered with issues as required.

Solved all issues related to claim adjudication and customer complaints and queries as received over telephone.

Researched and analyzed claim overpayments and funds requirements.

Reviewing claims working off project list or work queue. Maintain quality standards responsible to work suspended claims daily.

Experience in a production-based environment with an emphasis on quality outcomes.

Reviewing and adjudicating medical claims in accordance with cms claim processing guidelines.

Interface with other departments to obtain necessary information required for resolution of claims.

Provided prompt customer support to members, providers, billing departments and other insurance agencys regarding claims, appeals and eligibility.

Coordinated benefits while applying applicable deductibles, coinsurance and out of pocket costs.

Evenly distributed pending spreadsheet amongst team to quickly focus on the closure or reassignment of claims.

Environment: center city like medical claims and CMS 1500, Microsoft Word, Microsoft Excel, Adobe, Microsoft Outlook

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