Dhivya M
Chennai
Summary
Energetic, ambitious, and successful team person with 9 years of experience in the US health care industry, payer side.
Worked end-to-end process in Summary of Benefits and Coverage at Anthem INC, delivered client requirements, centralized management structure, standardized process, reduced duplication. Achieved business goals by handling inventory, making decisions based on quality analysis.
Worked end-to-end process in Claims Adjudication at Alignment Healthcare, it is a complete back-end process of Members (i.e., Persons of North Carolina, Maine, Florida, New York, California Etc..) insurance claims as submitted by the providers (Doctors) and deals with manually Reviewing all the treatments provided to them and every personal details of the member and provider are accessible through the client’s application if necessary.
Worked in Exela technology as junior Analyst in Quality Assurance Department. Client-United Healthcare, it is the process of analysis and review the Quality check findings of claim form’s ANSI format. Root casting analysis of technical, manual errors and Ensure the Quality.
Overview
9
9
years of professional experience
Work History
Junior Executive
Exela Technologies
05.2022 - 11.2023
- Ensures the ANSI standards claims, monitors internal processes, helps prepare for audits, and implements corrective actions based on audit findings.
- Focuses on identifying areas for improvement in processes to ensure they align with ANSI standards, suggesting corrective actions, and working to continuously improve quality and compliance.
- Conducting quality checks and tests on products or services to ensure they meet defined standards.
- Calibrating and feedback session with the peers
- Preparing Monthly Error dashboard
- Maintained and updated the organization’s SOPs and guidelines, ensuring all processes adhered to industry standards and regulatory requirements.
Senior Process Executive (Alignment Healthcare)
Cognizant Technologies Solutions
04.2018 - 12.2021
- Review and process healthcare claims based on the policyholder's coverage, medical necessity, and compliance with insurance guidelines.
- Verify the accuracy of claims by reviewing patient information, medical procedures, diagnosis codes (ICD-10), and billing codes (CPT/HCPCS).
- Ensure compliance with industry regulations such as HIPAA, CMS, and payer-specific policies, while processing claims.
- Handle claim adjustments, rejections, and appeals by reviewing supporting documents and coordinating with providers or members.
- Investigate claim denials and determine reasons for rejection, working to resolve issues in compliance with healthcare policies.
- Maintain accurate documentation of claims adjudication decisions, adjustments, and related communications for audit and tracking purposes.
- Use claims management systems (e.g., Ez-Cap, Optum360) to input data, track claim status, and update member/provider information.
Senior Process Executive (Anthem Health Insurance)
Cognizant Technologies Solutions
08.2014 - 03.2018
- Responsible for monthly and annual inventory volume reports.
- Auditing the Summary of benefits and coverage (SBC).
- Ensuring quality requirements and meeting deadlines.
- Troubleshooting the entry-level associates in understanding the process.
- Arranging the calls with client to understand the requirement, process updates and implement the same to the team.
- Achieved SLA's with accuracy.
- Organize and maintain process SOP/documents /updates emails.
- Collaborate & work with onshore and offshore peers.
Education
Bachelor of Science -
Bishop Heber College
04-2014
Diploma in Java Programming -
CSC
Skills
- Inventory Handling
- Data Analysis
- Team player
- Quality management
- Operations management
- Problem resolution
- Training and development
- Analytical Thinking
Timeline
Junior Executive
Exela Technologies
05.2022 - 11.2023
Senior Process Executive (Alignment Healthcare)
Cognizant Technologies Solutions
04.2018 - 12.2021
Senior Process Executive (Anthem Health Insurance)
Cognizant Technologies Solutions
08.2014 - 03.2018
Bachelor of Science -
Bishop Heber College
Diploma in Java Programming -
CSC
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