RangaswamyKaggundi

No***,*rdcross,Kanakanagar,RTNagara,

Bangalore–560030,Karnataka,India

adhsog@r.postjobfree.com

Mobileno-960-***-****

CareerObjective

Topursuemycareerinanorganizationthatprovidesmeanopportunitytogrowand Tocontributetotheoveralsuccessoftheorganization.

ProfessionalExperience:

Designation From To Organization

MedicalAnalyst 28/11/2019 Currentlyworking AxaBusiness ServiceHealthCare

Seniorprocess

Executive-Data

01/04/2015 21/03/2019 Cognizant

technology

Solutions

CardiacCare(CTVS) 14/12/2013 06/03/2015 BhagwanMahaveer JainHospital

Responsibilities:

MedicalAdjudication,MedicalDataAbstractionfromEMR(Electronic medicalrecords) IamdealingwithadifferentpatientmedicalrecordsEg:

*CABG:Acoronaryarterybypassgraftisasurgicalprocedureusedtotreatcoronaryheart disease.InthisscenariohealthcaremembersaregoingtosendEMR.Inthesemedicalrecords includespatientfasthistory,presenthistory,medicalmanagement,surgicalmanagement physiotherapymanagement,drugschartsandlabinvestigationreports.InthesescenariosI needtoabstractmedicalinformation which ismostimportanttothepatient'sconditions.

*Chronickidneydisease/treatment&managementacutekidneyfailure/treatment& management

*OBG/treatment&management.

*Oncologicaldisease/Surgery,radiation,chemotherapyandhormone therapy

*Paliative treatment&management

*Chronicheartdisease/treatment&management

*Osteoporosis/treatment&management

*Hematologicdiseases, disorders/treatment&management

*Endocrinedisorders/treatment&management

*Integumentarysystemdiseasestreatmentandmanagement FromApril2015asClinicalClaimReviewer(Medicalsummarization)and claimsenrollmentinUSHealthcareInsurance.

TheTOB,istoprovidethetableofbenefitstothememberswitha eligiblebilingandnon-bilingCPTcodewithamodifier.

ThePreserviceReviewisresponsibleforreviewingrequestsreceived fromproviders,using

Approvedprotocolsandcriteria.HealthcareGuidelines,Healthcare OperationsProtocols.TheRNisexpectedtoapprovethoserequests thatmeetmedicalnecessity,alongwithbenefitlevel,andthe contractualstatusoftheprovider/facilityasappropriateforalfuly- fundedlinesofbusiness.Thispositionisalsoaresourcetonewstaff andmaypreceptaswel.

Evaluateandassesseachrequestverifyingeligibilityandspecific product.

Determinebenefitlevelbasedonsiteofservice.

Utilizewrittencriteriatoapprove,Pendorsendthecasetothemedical directorforreview.

ClinicalclaimreviewinPredeterminationandDRGprocess. Predetermination:

Apredeterminationofbenefitsisareviewbymedicalstafftodecideifthey agreethatthetreatmentisrightforyourhealthneeds.Predeterminations aredonebeforeyougetcare,sothatyouwilknowearlyifitiscoveredby yourhealthinsuranceplanusingclinicalinformationwithmedical recordssummaryprovidedbytheproviders.

Clinicalpolicybuletins(CPBs)detailtheserviceandprocedurewe consideredmedicalnecessity,cosmetic,experimentalandinvestigation theyhelpustodecidewhatwewilandwilnot.

Electronicmedicalrecordsrequestingforreviewnotsubmittedby provider.

Makinganoutreachcaltoprovidersandmembersforinsufficient medicalrecordsandvalidCPTcodeanddiagnosiscode informationfor review.

Findingoutduplicatemedicalrecords.

Validationof Medicareplanandcommercialplan.

FindingoutofclaimsadjudicationandbilingstatusofCPTcodeand diagnosiscode.

MembervalidationforcreatingSOEandfindingoutofduplicateSOE.

Underpolicyandguidelinescreatingatemplate.

Sendingalettertorightproviderandrightmember

DRGbilingandpricing.

ReviewofDME(Durablemedicalequipment)medicalrecordswithCPBs. Aspeciallanguageplanunderprotocol.

Reviewofemergencyclaimifit'ssurgery's scheduled.

TrackingofTATclaimsforcomeoutoftheescalation.

Routingofclaimstoappropriatebinorassociate.

Maintainingofgoodaccuracyinproductionandqualityofreview

QualitycheckanalysiseveryweekandupdatingtoTLandAM. DRGPricing:

Adiagnosis-relatedgroup(DRG)isapatientclassificationsystemthat standardizesprospectivepaymenttohospitalsandencouragescost containmentinitiatives.TheDRGincludesanyservicesperformedbyan outsideprovider.Claimsfortheinpatientstayaresubmittedandprocessed forpaymentonlyupondischarge.

RootCauseAnalysis(RCA)isacomprehensivetermencompassinga colectionofproblemsolvingmethodsusedtoidentifytherealcauseofa non-conformanceorqualityproblem.

MaintainofaccuratequalityasperthepolicyandHIPAA(HealthInsurance PortabilityandAccountabilityAct)

DRGScreening:

ItistheinitialstepintheDRGprocesswherewewilverifyingthemember detailswhichfalsundertheDRGguidelines.

Responsibilities:TeamworkassistingtoTLorhisabsence. 1)Takingteamtodiscussonnewscenariosofclaims.

2)MaintainingtrackersfordailyproductionandreportingtoAM. 3)CheckingforRCA.

4)Shadow trainingfornewassociateandmakethemtobecomefamiliar. 5)Inventoryassignmenttoassociatesandtrackingofoldclaimstatus updatetoTL

6)Maketheteamtoparticipateinmonthlyrecognizeandawardforthe bestperformance.

QualifyingSummary

GoodknowledgeofAnatomy&Physiology.

Inclinationtoenhanceknowledge.

GoodknowledgeofMedicalTerminology.

EfficientinMicrosoftOfficeSoftware,includingWord,Excel,andPower point.

Goodcommunicationandinterpersonalskils.

Dedicatedtomeettargetsintime.

AcademicCredentials

Qualification University Institution Year Percentage PCB.ScNursing RGUHS Shanthidhama

Collegeof

Nursing

2011-2012 60%

Diplomain

Nursing

KarnatakaState

Diplomain

Nursing

Examination

Board

MotherTeresa

Schoolof

Nursing

2005-2007 59%

PUC Departmentof

Pre-University

Education

GovernmentPU

college

2004 66.16%

PersonalProfile

Nationality : Indian

MaritalStatus : Single

DateofBirth : 08.06.1986

Sex : Male

LanguagesKnown : Kannada,English,(R/W/S)

Addressforcommunication : #111,3rdcross,Kanakanagar,RTNagar Bangalore

Declaration

IdeclarethattheinformationfurnishedaboveistruetobestofmyknowledgeandI bearthe

Responsibilityfortheabovementionedparticulars.

ThankingYou,

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