Chethan Kumar M S
Claims Associate
Bangalore
Summary
Claims Associate processing and adjudicating healthcare claims with CIW and WGS for accurate benefit application and compliance. Reviews policy details, medical documentation, and claim edits to resolve high-dollar and complex cases while maintaining a 100% accuracy rate on documented work. Supports new joiner training, audit updates, and benefit coding across medical, dental, vision, and pharmacy configurations.
Overview
1
1
Language
4
4
years of professional experience
Work History
Claims Associate
Carelon Global Solutions
05.2022 - 07.2026
- Processed, adjusted, and adjudicated claims using CIW and WGS applications with consistent accuracy and compliance.
- Analysed policy details and medical documentation to ensure correct claim resolutions with a 100% accuracy rate.
- Routed claims to relevant departments for additional information when necessary to ensure smooth adjudication.
- Mentored new joiners, providing process training and addressing operational queries.
- Collaborated with healthcare professionals to collect and verify patient details and eligibility
- Resolved claim edits and pop-ups efficiently and maintained strong knowledge in benefit coding. Participated in system training to enhance workflow and software proficiency.
- Reviewed and reworked claims to ensure accuracy, maintaining member satisfaction and process quality.
- Supported audit updates, ensuring all team members were aligned with new processes and compliance requirements.
- Managed special projects including 84 adjustments, sweeps adjustments, adjudication, accumulators, ravens commercial claims, and high-dollar claims.
Education
Bachelor of Commerce - undefined
Bangalore University
01.2020
PUC - undefined
Kuvempu First Grade College
01.2017
SSLC (Secondary School Leaving Certificate) - undefined
Karnataka State Board
01.2015
Skills
Claims adjustment & adjudication
Claims investigation & analysis
Benefit coding
Claims routing
Accumulators processing
CIW & WGS system proficiency
Microsoft Office Suite
Member eligibility verification
Audit support
Claims workflow training
ACHIEVEMENTS & AWARDS
Employee of the Month – Recognized for exceptional performance and commitment to accuracy, Impact Award (3 Times) – For consistently maintaining high productivity and quality standards in claims adjudication.
Timeline
Claims Associate
Carelon Global Solutions
05.2022 - 07.2026
SSLC (Secondary School Leaving Certificate) - undefined
Karnataka State Board
PUC - undefined
Kuvempu First Grade College
Bachelor of Commerce - undefined
Bangalore University