J. DURGA
Sr Process Associate
Chennai
Summary
Results-oriented Senior Process Associate with extensive expertise in health insurance claim evaluation, quality assurance, and comprehensive claims processing. Recognized for exceptional problem-solving abilities and a proven track record of driving process improvements that enhance operational efficiency. Committed to delivering high-quality, accurate results in fast-paced environments, ensuring optimal outcomes for clients and the organization. A proactive approach to challenges fosters a culture of excellence and continuous improvement within teams.
Overview
14
14
years of professional experience
Work History
Sr process Associate
NTT Data Services
06.2021 - Current
- Manage the support mailbox and resolve claim-related queries within SLA timelines.
- Process standard health insurance claims with high accuracy and compliance with policy guidelines.
- Review and process reinsurance claims, validating high-value cases and preparing accurate recovery reports.
- Support audits, quality activities, and process improvements through effective coordination and documentation.
- Remote - DLF at Porur
Quality Analyst (QA)
Sutherland Healthcare Solution
08.2015 - 07.2017
- Handle multiple inpatient and outpatient claim queues with accuracy and efficiency.
- Specialize in corrected claims and appeal claims for INN/OON providers.
- Allocate audits and manage internal/external quality reports.
- Participate in rebuttal calls and support operations in issue resolution.
- Contribute to process improvement by validating and sharing improvement ideas.
- Conduct online assessments and share performance scores with operations.
- Online - The Sriram Gateway
Claims Examiner
Dell International Pvt. Ltd
01.2012 - 03.2015
- Highlight your accomplishments, using numbers if possible.
- Process and adjudicate health insurance and flexible spending account (FSA) claims in accordance with plan policies, consistently maintaining 98–99% accuracy in claim decisions.
- Evaluate member-submitted charges and determine appropriate payment amounts, achieving daily productivity rates.
- Apply business rules and policy guidelines to approve or deny claims, ensuring 100% compliance with regulatory and internal audit standards.
- Review payer statements (EOBs) to validate benefit application and resolve discrepancies, contributing to a 15–20% reduction in rework through accurate first-pass processing.
- Execute partial payments and reductions based on policy rules, maintaining over 98% adherence to benefit coverage criteria.
- Process high-dollar hospital and medical claims with strong attention to detail, consistently achieving zero percent financial leakage across monitored audit cycles.
- Handled high dollar claims for both hospital and medical claims
- Online - DLF at Porur
Education
MBA HR -
Amity University Online
01.2025
MSC - undefined
University Of Madras
01.2014
BCA - undefined
Annai Velankanni College
01.2011
Skills
Team Collaboration
Able to work independently as well as in a team
Analytical Skills
Possesses a good understanding of the claims process
Positive Attitude
Accomplishments
- Top performer - Auditor
- Twice recognized as Top Performer in auditing at Sutherland
- Award for Macro Creation
- Created a spreadsheet macro to enhance auditing efficiency
Timeline
Sr process Associate
NTT Data Services
06.2021 - Current
Quality Analyst (QA)
Sutherland Healthcare Solution
08.2015 - 07.2017
Claims Examiner
Dell International Pvt. Ltd
01.2012 - 03.2015
MSC - undefined
University Of Madras
BCA - undefined
Annai Velankanni College
MBA HR -
Amity University Online