Mahendra Singh Rana

PEOPLE / TEAM: -

● Engagement plans for team members.

● Managing attrition and absenteeism and maintain EWS (Early warning system) for the team for tracking and proactively addressing people issues.

● Identify & groom high potential team members for the next level.

● Performance appraisals for team members.

● Performance management grid & take immediate steps for any variance.

● Performance report (presentation/visual boards) is shared with team on a regular basis.

PROJECT/PROCESS: -

• Achieve Quality Service Level Agreements / metrics.
• Random quality audit, Re-Butt / Appeal Process, Escalation Handling.
• Managing operations rigor around daily huddles, visual, knowledge management, cross training.
• Doing team interaction on a monthly 1-1 session with associates to discuss their performances and improvement plans.
• Identify opportunity areas for improvement in quality & and productivity
• Resource utilization through cross training initiatives and buffer management.
• Preparing and uploading the monthly incentives
• Liaison with support functions like HR, IT facilities to resolve issues.
• Engage with other processes to understand and implement best practices.
• Daily taking care of all the buckets (Queue) and coordinating with SMEs. and
• Doing team hurdles and quality calls with the QA teams on a weekly basis to improve team quality and help reduce escalations.
• Resolved conflicts between team members in an effective manner.
• Delegated work to staff, setting priorities and goals.

BUSINESS: -

• Reporting with business leaders for review on a periodic basis.
• Meeting the established productivity, schedule adherence, and quality standards consistently.
• Conducted regular performance reviews for employees to identify areas of improvement.
• Identified cost-saving measures that could be implemented without compromising quality standards.
• Worked well in a team setting, providing support and guidance.
• Managed time efficiently in order to complete all tasks within deadlines.

• On 2019 i got promoted as SME, i was handling new process for 18 months (HEDIS) – (Healthcare Effectiveness Data and Information Set)
• To check and collect and review data from patient charts and other medical records from hospitals, doctors' offices and various health care providers to measure and help improve quality
• Measures like Col Gaps, BCS Gaps, HbA1C gaps, Diabetes Eye Exam (DRE) and Diabetes Microalbumin gaps.

• Review medical information such as attending physician statements, lab reports, paramedics exams, and/or other related underwriting information consistent per client specifications
• Review case narratives & queries on drug interaction and adverse effects on drugs
• Performing quality checks by doing case analysis and peer reviews
• Perform the medical review, validate follow-up request and perform the medical assessment
• Look at each medical record to check for missing documentation
• Creating precise and informative medical summaries of patients
• Interact and work with managers regarding problem-solving and understanding the process
• Prioritize workloads to ensure expedited cases are processed within defined timelines
• Responsible for the timely completion of individual cases and meeting the SLA for data entry and case analysis activity as per SOP.
• Entered patient insurance, demographic and health information into software and confirmed records.
• Adhered to all HIPAA regulations when handling confidential patient information.
• Performed audits of medical records according to established protocols.
• Analyzed patient information and data to identify any discrepancies or errors in the documentation.
• Compiled reports summarizing findings from case reviews.
• Collaborated with others to discuss new opportunities.
• Prioritized and organized tasks to efficiently accomplish service goals.

• Worked as claim processor– Based on preauthorization as well as medical records of patients then verify the medical impairment (diagnosis) with prior- auth to check claim procedure codes to process the claim to pay or deny claim based on policy message which is provided by health insurance (BUPA)
• Worked on special cases like NHS (national health service), Cash benefits and dental claim, member payee
• Verified and reviewed data on insurance applications and policies such as age, name, principal sum, and address
• Reviewed medical records for accuracy, completeness and regulation compliance while maintaining HIPAA regulations
• Reviewed denials and submitted appeals to gain approval from insurance companies
• Documented all prior authorization information in patient profiles, including approval dates and prior authorization numbers.