Hena Goudperu
Hyderabad
Summary
Detail-oriented and results-driven professional with 6 years of experience as a Senior Associate in Collections and a Quality Analyst in Prior Authorization. Strong knowledge of ICD-10, CPT, HCPCS, and insurance policies, with a proven track record in improving operational efficiency and ensuring regulatory compliance.
> To achieve exceptional personal and professional growth > Looking for the opportunity to utilize my strength and build up my career.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Quality analyst in prior authorization and referral specialist
Reventics Pvt Ltd
Hyderabad
10.2024 - Current
- Handling a team of 20 plus associates, surpassing monthly performance goals with a sustained KPI adherence rate of over 95%.
- Streamlined operational workflows, enhancing team efficiency and reducing error rates through process optimization and best practice implementation.
- Facilitated weekly performance evaluations and designed personalized development plans to foster continuous employee growth and drive performance improvement.
- Partnered with cross-functional teams to align efforts and successfully achieve key project milestones and performance targets.
- Auditing invoices for in-patient and out-patient services for various departments. (Radiology, Cardiology and Surgery)
- Working for various insurance plans, including federal, managed care, PPO, EPO, and HMO plans.
- Review submitted prior authorization requests to verify the accuracy of patient details, diagnosis codes, procedure codes, medical necessity, and compliance with insurance payer policies.
- Checking the validity of referral requests, including patient eligibility, referring physician details, and appropriateness of the requested service.
- Identifying trends and patterns in errors or discrepancies within the prior authorization and referral process to pinpoint areas for improvement
- Ensuring adherence to all relevant healthcare regulations, payer guidelines, and internal policies regarding prior authorization and referral procedures.
- Providing constructive feedback to prior authorization and referral specialists on areas requiring improvement and conducting training sessions to address identified issues.
- Generating detailed reports on quality metrics, error rates, and performance trends related to prior authorization and referral activities.
- Mediated team conflicts and led targeted training sessions to enhance collaboration and drive productivity gains.
Quality analyst under prior authorization
Sutherland Healthcare Solutions
Hyderabad
10.2022 - 10.2024
- Process Monitoring and Evaluation
- Ensure that requests are processed accurately according to policies and payer requirements.
- Ensure adherence to healthcare regulations (HIPAA, CMS guidelines, etc.) and company standards, workflows to identify discrepancies or inefficiencies.
- Quality Assurance and Improvement
- Create and implement quality metrics to evaluate the efficiency and accuracy of prior authorization processes.
- Recognize areas where errors commonly occur and recommend improvements.
- Reporting and Documentation
- Prepare regular reports on quality metrics, audit findings, and compliance issues for management.
- Ensure that all prior authorization documentation is complete, accurate, and up to date.
- Provide feedback to prior authorization teams to enhance their performance based on QA findings.
Sr. Associate Collection
Sutherland Healthcare Solutions Pvt Ltd.
Hyderabad
08.2019 - 10.2022
- Review the claim allocated and check the status by calling the payer or through the IVR /Web Portal.
- Accurately input procedure codes, diagnosis codes, and patient information into billing software to generate up-to-date invoices. Get prior authorization approval from insurance firms and nurse managers.
- Obtaining pre-approval from insurance companies for medical procedures, treatments, and services
- Appeal insurance companies after prior authorization refusals. Provided respectful assistance to patients and insurance companies.
- Reviewed account information to confirm that insurance information is accurate and complete.
- Checked claims coding for accuracy with ICD-10 standards. Performed insurance verification, pre-certification, and pre-authorization.
- Gathered medical history and information from the patient.
Education
MBA -
St. Pious X PG MBA College for women
01-2019
Intermediate -
St. Ann's junior college for girls
B.com - Computer
St. Ann's Degree College for women
01-2016
SSC -
Nalanda High School
Neredment01-2011
Skills
- Prior Authorization Systems: Epic, All scripts, and CoverMyMeds
- Healthcare Regulations: HIPAA, HITECH, Medicare/Medicaid, ACA compliance
- Healthcare Knowledge: ICD-10, CPT, HCPCS, and insurance policies
- Other Tools: Microsoft Office (Excel, Word, PowerPoint)
- Capable of managing multiple tasks simultaneously
- Demonstrates full commitment to work
- Quick learner with the ability to adapt and acquire new skills based on the organization's needs
Certification
- Regularly audit authorization
- HIPAA Compliance Training
- Certified Epic software
- Certified for all scripts
- Investigate errors or delays to determine their causes and suggest corrective actions.
Recognition
I received the monthly best performance award two times in Sutherland Healthcare Solutions, Awarded the Quality Star of the Month
Personal Profile
I received the monthly best performance award two times in Sutherland Healthcare Solutions, Awarded the Quality Star of the Month
Timeline
Quality analyst in prior authorization and referral specialist
Reventics Pvt Ltd
10.2024 - Current
Quality analyst under prior authorization
Sutherland Healthcare Solutions
10.2022 - 10.2024
Sr. Associate Collection
Sutherland Healthcare Solutions Pvt Ltd.
08.2019 - 10.2022
MBA -
St. Pious X PG MBA College for women
Intermediate -
St. Ann's junior college for girls
B.com - Computer
St. Ann's Degree College for women
SSC -
Nalanda High School