KOMAL N
Healthcare Insurances claims Specialist
Banglore
Summary
To pursue a rewarding career in a dynamic and innovative organization, where I can leverage my expertise to drive meaningful contributions, embrace challenges, and foster both personal and professional growth within a high-performance environment.
Overview
5
5
years of professional experience
5
5
years of post-secondary education
4
4
Languages
Work History
Senior Process Executive
Cognizant Technology Solutions India Private Limited
Banglore
10.2023 - 12.2024
- Ensured stringent quality standards in claims processing for the HCSC project, maintaining compliance with operational benchmarks and regulatory guidelines.
- Oversaw and executed critical healthcare operations, including benefit validation, pricing configuration, health plan testing, and XML-based system assessments.
- Processed diverse healthcare claims for medical, hospital, and home services, ensuring accurate payment release, pricing verification, bill review, and reimbursement handling.
- Reviewed and adjudicated health insurance claims, consistently meeting and exceeding TAT (Turnaround Time) targets.
- Collaborated cross-functionally with teams to align with client expectations and achieve internal SLA (Service Level Agreement) objectives.
- Managed premium and deductible follow-ups, effectively resolving customer concerns with a solution-oriented and professional approach.
- Addressed provider queries, delivering expert clarifications on claim adjudication, policy terms, and technical issues.
- Verified insurance requests, analyzed medical data, and evaluated the medical necessity and justification for procedures to ensure compliance and accuracy.
Dental Spec Claim Examiner
Empower Retirement
Banglore
10.2022 - 10.2023
- Managed dental claims for Canadian policyholders using the BEN application as part of the Canada Life project.
- Reviewed and investigated complex health and dental claims submitted by plan members and healthcare providers to ensure accurate processing.
- Verified and audited incomplete claim submissions, ensuring data accuracy and adherence to adjudication guidelines.
- Made informed payment decisions by meticulously applying adjudication rules and compliance protocols.
- Collaborated with dental providers to gather essential documentation and clarify patient histories for efficient claims processing.
- Conducted in-depth eligibility verification, issuing official eligibility communication letters to customers.
- Authorized and finalized payments for providers, dentists, and members after thorough claim assessments.
- Resolved provider inquiries and member queries, delivering prompt solutions and clarifications on claims and policy details.
- Negotiated fair settlements between insurance providers and policyholders to resolve disputes amicably.
Insurance Processor Consultant
Hinduja Global Solutions Limited (HGS-Sagility)
Banglore
12.2019 - 10.2022
- Performed detailed analysis of fresh and aged claims, ensuring comprehensive documentation and proper authorization prior to processing.
- Managed complex claim denials, identifying root causes and implementing corrective measures by liaising with insurers and healthcare providers to ensure resolution.
- Processed and adjudicated claims, expertly handling deductibles, co-pays, co-insurance, and provider settlements to ensure accurate reimbursement.
- Conducted comprehensive audits, ensuring compliance with regulatory standards and implementing corrective actions to mitigate discrepancies.
- Approved and authorized high-value claims exceeding $10,000, utilizing expert claims assessment skills to mitigate financial risks.
- Delivered superior customer service, addressing inquiries and resolving concerns for members, providers, and insurers with professionalism and efficiency.
- Ensured timely follow-up and completion of claims, maintaining accurate and updated documentation for audit readiness.
- Verified claim validity, ensuring coverage eligibility and reviewing submissions for completeness, accuracy, and compliance with policy terms.
Education
Bachelor of Commerce -
University Of Mysore
Hassan 11.2016 - 05.2019
Pre University - Commerce
BEG First Grade College
Hassan 03.2014 - 03.2016
Secondary School Certificate - General
Government Girls High School
Hassan 04.2013 - 04.2014
Skills
- Strong interpersonal skills
- Effective communication
- Teamwork and collaboration
- Customer services focus
MS Excel,MS Word, MS PowerPoint, MS Office 365,
Tally ERP 9
- CMS/UB Claims processing
Medical Claims
- Claims Investigation and Research
- Expertise in claims adjustment
Operational excellence
External party relationship management
Timeline
Senior Process Executive
Cognizant Technology Solutions India Private Limited
10.2023 - 12.2024
Dental Spec Claim Examiner
Empower Retirement
10.2022 - 10.2023
Insurance Processor Consultant
Hinduja Global Solutions Limited (HGS-Sagility)
12.2019 - 10.2022
Bachelor of Commerce -
University Of Mysore
11.2016 - 05.2019
Pre University - Commerce
BEG First Grade College
03.2014 - 03.2016
Secondary School Certificate - General
Government Girls High School
04.2013 - 04.2014
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