Ambica Jadav
Appeals Representative
Hyderabad
Summary
Healthcare professional with specialized expertise in handling appeals and grievances. Proven track record of resolving complex cases efficiently and positively impacting client satisfaction. Known for collaborative approach, adaptability, and strong problem-solving abilities, key to driving successful outcomes.
Overview
7
7
years of professional experience
4
4
Languages
Work History
Appeals Analyst
Optum Global Solutions
05.2019 - Current
- Provide operational support by reviewing, researching, investigating, analyzing, and finding the request and medical records related to Appeals and Grievances quality reviews, and ensure data is entered into the system for tracking and closing the received requests from the provider/member within the time frame, with good quality of production and meeting the daily targets.
- Handling standard (7 calendar days) and expedited (72 hours) turnaround time of verbal and non-verbal appeals received from various channels filed by members, authorized representatives and provider.
- Follow up with onshore team regarding escalation emails and inventory Management, ensuring adherence to all CMS guidelines and that processing deadlines are handled in compliance with CMS regulations and timeline.
- Follow up with onshore for member and provider outreach for additional information and make the final decisions based on plan policies, medical necessity, and regulatory guidelines. Conduct a detailed analysis of appeal cases to determine whether coverage decisions should be upheld or overturned.
- Identify the correct resource and reroute inappropriate work items that do not meet the appeal criteria.
- Handled escalated cases adeptly, applying advanced problem-solving skills to resolve highly complex or contentious issues.
- Improved the efficiency of the appeals process by reviewing and analyzing claim denials and discrepancies.
- Investigated fraudulent activities and recommended corrective actions, safeguarding company resources and maintaining the integrity of the appeals process.
- Championed continuous improvement initiatives within the appeals department, implementing process enhancements that led to increased efficiency and productivity.
- Conducted ongoing training sessions for staff on regulatory updates and new procedures, ensuring compliance with changing industry standards.
- Managed high volume of cases, prioritizing tasks effectively and meeting strict deadlines for appeals resolutions.
- Collaborated with interdisciplinary teams to ensure accurate claims adjudication, reducing errors and inconsistencies in the review process.
- Maintained detailed records and organized documentation to facilitate smooth appeals processing, ensuring all relevant information was readily available for review.
- Mentored new team members on departmental protocols and best practices, fostering a positive learning environment within the team.
- Enhanced customer satisfaction with timely resolution of appeals, addressing concerns thoroughly and professionally.
- Researched claims and incident information to deliver solutions and resolve problems.
- As an OJT, supporting the team to resolve queries, auditing the cases to reduce errors, and improve the A&G process and performance.
Education
Post-Graduation MBA - Finance
Bharat PG College For Women's
Hyderabad, India 05.2001 -
Graduated B.COM -
Siddhartha Degree College For Women's
Hyderabad, India 05.2001 -
Intermediate CEC -
Gowtham Junior College
Hyderabad, India 05.2001 -
SSC -
Ushodaya High School
Hyderabad, India 05.2001 -
Skills
Teamwork and collaboration
Customer service
Problem-solving
Time management
MS office
Team leadership
Multitasking Abilities
Self motivation
Workload prioritization
Accomplishments
- Received Bravo Points and Recognition for the outstanding performance and support.
- Received appreciation emails for maintaining quality of Production and Efficiency.
Timeline
Appeals Analyst
Optum Global Solutions
05.2019 - Current
Post-Graduation MBA - Finance
Bharat PG College For Women's
05.2001 -
Graduated B.COM -
Siddhartha Degree College For Women's
05.2001 -
Intermediate CEC -
Gowtham Junior College
05.2001 -
SSC -
Ushodaya High School
05.2001 -