Juhi Wagde

• Conducted audits to identify areas for process improvement and risk mitigation for one of the Insurance payers from Healthcare.
• Performed gap analysis between current state processes, procedures and desired future state processes, procedures.
• Developed corrective action plans in response to audit findings.
• Documented investigation results including root cause analysis and corrective action recommendations.
• Compiled data related to quality assurance activities and prepared reports for management review.
• Analyzed data to support quality control initiatives and reporting requirements.
• Reviewed documentation for accuracy and adherence to company policies.
• Monitored compliance with quality standards and regulatory requirements.
• Participated in team meetings to discuss strategies for improving customer experience.
• Reviewed and resolved client concerns and issues, researching relevant details and clearly communicating solutions.
• Contributed innovative ideas and solutions to enhance team performance and outcomes.
• Conducted Quality Huddles on weekly basis.
• Provided feedback and coaching to team members on performance improvement.
• Worked with cross-functional teams to achieve goals.
• Developed and implemented Lean Six Sigma methodologies to identify, analyze and improve one of the new internal process.

• Implemented underwriting guidelines while assessing risk factors accurately.
• Reviewed and evaluated Medical Underwriting documents like SOH (Statement of Health) to approve, suspend or decline requests.
• Worked on Group enrollment for U.S. Life Insurance and communicated with clients to inquire about the continuing needs.
• Conducted data cleaning and validation to ensure accuracy in reports.
• Translated raw data into meaningful information using statistical techniques.
• Analyzed large datasets to identify trends and support business decisions.

Worked on Medicare claims and DME (Durable Medical Equipment) process, Claims denial management, Medicare Appeals, ERL Rejections, Revenue Cycle Management Cycle, Physician billing. Reviewed patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under policies.

Client Reporting-

• Prepared detailed reports on claims status and processing timelines.
• Assessed medical records for coverage eligibility and benefit accuracy.
• Prepared detailed reports on claim status, payment history, and other relevant information.

Team Mentoring-

• Trained the team members and handled the team by assisting them and resolving queries proactively on a daily basis.
• Worked on Quality improvement of team members by performing Quality analysis on the claims and eligibility worked by team.
• Demonstrated leadership by making improvements to work processes and helping to train others.

• Reviewed insurance medical claims for accuracy and compliance with policies.
• Communicated with healthcare providers to resolve claim disputes effectively.
• Managed appeals process by gathering necessary documentation and submitting requests.
• Collaborated with billing teams to ensure accurate coding and billing practices.
• Utilized electronic health record systems for tracking claim statuses efficiently.
• Utilized critical thinking skills to evaluate denial patterns and recommend process improvements.
• Prepared and submitted appeal letters and necessary documentation to overturn unjustified denials.
• Utilized medical billing software to track and manage denied claims efficiently.