Dileep Kumar Ratnala
Hyderabad
Summary
Experienced Medical Claims Adjuster with deep knowledge of Professional and Institutional medical claims industry. Eager to continue being successful at contributing to meeting team goals by managing multiple priorities with a positive attitude, utilizing interpersonal skills, excellent time management and problem-solving skills. Strong reporting and research skills. Strong command of conflict resolution and negotiation combined with excellent reporting and research skills.
Overview
8
8
years of professional experience
Work History
Medical Insurance Claims Adjudicator/ Trainer
Legato Health technologies
Hyderabad
01.2019 - 07.2022
- Reviewed and adjudicated claims up to specified dollar limit
- Processed claims within performance guidelines of the department, including quality and timeliness
- Understands provider contracts
- Examined and interpreted all relevant documents included with the claims
- Responded to claim-specific questions and escalations as applicable.
- Partnered with leadership on any questionable claim activity
- Understands logic of standard medical coding (i.e
- CPT, ICD-10, HCPCS, etc.)
- Determined accurate payment criteria for clearing pending claims based on defined Policy and
- Procedures
- Researched claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed
- Worked high volume of repetitive claims
- Identified claims with inaccurate data or claims that require review by appropriate team members
- Completed special projects as assigned and supports other Claims Department team members in assigned projects
- Complied with all departmental and Company policies and procedures
- Consistently demonstrated compliance with HIPAA regulations, professional conduct, and ethical practice
- Worked to encourage and promote Company culture throughout the organization
- Managed large volume of medical claims on daily basis
- Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations
- Paid or denied medical claims based upon established claims processing criteria
- Used administrative guidelines as resource or to answer questions when processing medical claims
- Reviewed provider coding information to report services and verify correctness
- Checked documentation for accuracy and validity on updated systems
- Generated, posted and attached information to claim files
- Modified, updated and processed existing policies
- Reviewed outstanding requests and redirected workloads to complete projects on time
- Coordinated with contracting department to resolve payer issues
- Worked independently with minimal supervision, setting priorities and demonstrating excellent project management skills
- Worked with Quality Assurance to identify department needs, develop training materials and implement strategies to prepare employees thoroughly for job demands
- Created curricula, instructions, documents and written tests for various types of training courses
- Modified, updated and processed existing policies
- Advised executives on best practices for employee growth and productivity goals
- Identified workers with specific skill sets to recommend for promotions.
- Mentored new members of claims staff in proper procedures.
Process Executive
Cognizant technologies
Hyderabad
09.2014 - 01.2019
- · Auditing claims as per given updates from onshore.
- · Provide Quality score reports periodically and minimize errors by following a statistical approach.
- · Provide analysis on the adjudication and strive to automate the process of resolving medical claims.
- · Review and update the SOP .
- · Perform Claim adjudication report the status by EOD.
- · Identify and appraise any gaps with in operational processes proactively to the Engagement Leadership and also suggest tactical remedies to the findings.
- · Recognize any areas of concern within the Operations team and provide feedback.
- · Conduct training programs across the project team and help them understand the process.
Education
B.Pharmacy - Pharmacy
Adarsa College of Pharmacy
Rajahmundry04.2012
Intermediate - Bipc
Surya College
Jangareddigudem04.2008
High School Diploma -
Surya Model School
Jangareddigudem04.2006
Skills
- Claim Form Analysis
- Claims Procedures
- Complex Problem-Solving
- Coding Review
- Insurance Terminology
- Team Training
- Insurance Industry Experience
- Claims Processing
- Claims Evaluation
- Critical Thinking
- Decision Making
- Active Listening
- Team Collaboration
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Medical Insurance Claims Adjudicator/ Trainer
Legato Health technologies
01.2019 - 07.2022
Process Executive
Cognizant technologies
09.2014 - 01.2019
B.Pharmacy - Pharmacy
Adarsa College of Pharmacy
Intermediate - Bipc
Surya College
High School Diploma -
Surya Model School
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