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Medical Manager

Vellore, Tamil Nadu, India
March 09, 2021

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Venkatesh Ethiraj


Mobile #: +916********* / WhatsApp 056*******


Seeking a position of Coding & Claims Auditor - Manager in Insurance domain where I can utilize my extensive medical and computer apparel knowledge and strong organizational abilities. And to build a long term career in challenging business sector to utilize my professional skills and experience in the best possible way in dynamic and stable workplace. Summary:

Overall 15-year experience in RCM as Medical Coding & Claims Manager, derives the organization as a set path in sorting out the revenue into good profit, strategy towards the insurance methodology, internal and external Audits for the betterment of Organization.

Owns the RCM team – total of 60 members. Drives the team in different processes for optimal outcome (Approval, Medical Coding, Billing, Submission, Resubmission, Reconciliation). Utilize the manpower trend and operational activities as per department needs.

Advisory to Governance, Leadership and Direction (GLD members) on RCM.

Member of Committee MOI (Management of Information) Chairman to direct the medical records compliance, root cause analysis, risk mitigation to direct the physician and medical team for better outcome of documentation and revenue income.

JAWDA (Tasneef) certification process owner on complete claim process including process implementation and outcomes. Responsible on certification KRA associated with DOH adjudication rule and medical coding guidelines.

Link of quality management system advisory in regards to JAWDA (Quality) DOH indicators, Coordinator vs Validator. Directly involved during the audits on KPIs.

Internal planning on revenue cycle management audits on coding guidelines. Training awareness, outcome of audits and inspection to comply with medico-legal, insurance requirements and patient safety.

2-benchmark system with analysis of Six Sigma process for revenue outcome with data validation and interview of payers.

Core responsible on Daman Evidence-based Reimbursement Program (EBRP) and compliance. A study-based trial and inputs to Daman was suggested and appreciated in auditing and compliance.

Previous worked as Claims Audit officer in NAS Administration TPA Service Pvt Ltd, Abu Dhabi for 5 Years

Auditing all the providers on the IR-DRG payment system, E/M Coding, Medical Necessity and Medical Documentation of E-Claims and identifying the fraud & Abuse o Billing for services that were not medically necessary o Charging excessively for services or supplies

o Misusing codes on a claim, such as up-coding or unbundling codes o Billing for non-rendered services

Extremely knowledgeable with regard to Medical Coding guidelines and coding techniques

(ICD-9-CM, ICD-10-CM, CPT-4, HCPCS, and DRG's).

Excellent in Ms-Excel


Degree : MBA (Insurance & International Business Management) Certified by International Institute of Business Management, India

: B. Sc (Science with Math’s)

Certified by Madras University

Voorhees College, Vellore - India

Quality Credential : CSSB (Certified Six Sigma Black Belt) Certified by International Institute of Business Management, India Coding Credential : CPC-P (Certified Professional Coder - Payer) Certified by AAPC, USA

: CPC-H (Certified Professional Coder - Hospital)

Certified by AAPC, USA

: CPC (Certified Professional Coder)

Certified by AAPC, USA

: DMRT (Diploma of Medical Record Technology)

Certified by CMAI, India

Computer Software : PGDCA (Post Graduate Diploma in Computer Application) Oracle-VB, C++, MS Dos-Windows

Work Experience:

1. Medcode

Vellore, Tamilnadu, India

Period (Feb 2020 to till date)

Medical Coding – Process & Auditing (Outpatient, Daycase & Inpatient) RCM Rejection Analysis, Medical Coding Rule Engine, Medical Coding Training 2. Universal Hospital

Abu Dhabi, Po. Box #: 5056

Period: 2.5years (Jan 2017 to Nov 2019)

Designation: Sr. Manager RCM (Medical Coding & Insurance) 3. NAS Administration TPA Service Pvt Ltd

Abu Dhabi, Po. Box #: 44505

Period: 5years (July 2010 to Dec 2016)

Designation: Claims Audit Officer (Working for payer side as Medical Claims Auditor) 4. TTK Healthcare Service Pvt Ltd (TPA)

#2, H.B Complex, BTM 1st Stage, BTM Layout, Bangalore 560068, India Period: 2yrs and 5 Months (Jan 2008 to July 2010)

Designation: Team Leader (Working for payer side as Team Leader) 5. Cambridge Integrated Services India Pvt Ltd

SJR I Park, No.13, 14 & 15, EPIP Industrial Area, Whitefield Bangalore - 560 066, India Period: 2yrs and 5 Months (July 2005 to Dec 2007)

Designation: Sr. Medical Coder & Sr. CSR (Working for payer side as Quality Review of USA provider billed claim)

6. Processmind Service Pvt Ltd

Koramangala, Bangalore - 560095.

Period: 1yr and 5 Months (Jan 2004 to July 2005)

Designation: Medical Coder (Coding for multi speciality of USA providers claim) Personal Profile:

Date of Birth : 30-May-1976

Sex : Male

Nationality : Indian

Permanent Address : No: 24 Vallalar St,

Govindaraj Nagar,

Otteri, Vellore, Tamil Nadu -632002 (India)

Passport No : K0783902 (Expiry – 2021)


I consider myself adept with communications and possess good knowledge of Medical Coding. I am also confident of the soft and interpersonal skills I possess and my ability to work in a team. I hereby declare that all statement made in the application are true, complete and correct to the best of my knowledge and belief.


Date: Yours faithfully

Venkatesh Ethiraj

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