Manoj B K

• Client: CVS Health (PBM division), with a focus on serving clients such as Centene and Blue Cross Blue Shield

Responsibilities:

Adjudication Support:

• Collaborated with CVS Health's pharmacy benefit management (PBM) division to provide adjudication support to prominent insurance clients including Centene and Blue Cross Blue Shield.
• Ensured the accurate processing of insurance claims by analyzing benefit details and configuring systems accordingly.

System Testing and Validation:

• Conducted comprehensive testing of healthcare adjudication systems, ensuring alignment with client requirements and regulatory standards.
• Utilized query-based testing methods to validate benefit details coded in AS400 against client specifications, ensuring system accuracy and compliance.
• Executed claim testing scenarios to simulate real-world scenarios, validating rejection codes and payment processes to maintain system integrity.

Automation and Process Improvement:

• Developed Python scripts and utilized openpyxl library to automate data processing tasks, streamlining workflows and reducing manual effort.
• Implemented process improvements to enhance efficiency in data extraction, validation, and reporting, contributing to cost savings and operational excellence.

Issue Resolution and Stakeholder Communication:

• Took ownership of reported issues, conducting root cause analysis and implementing corrective actions to ensure timely resolution.
• Collaborated effectively with cross-functional teams and stakeholders, providing clear and concise communication throughout the issue resolution process.
• Developed new analytical models that improved forecasting accuracy and reduced risk exposure.