Nageshwari Ramanujam
Chennai
Summary
- Experienced Healthcare Operations Manager with a strong background in medical auditing and payment integrity. Skilled in leading teams, enhancing process efficiency, and driving innovative solutions in healthcare fraud prevention. Proven ability to deliver high-quality results in fast-paced, data-driven environments. Committed to continuous learning and professional growth.
Overview
17
17
years of professional experience
1
1
Certificate
Work History
Manager- Business Analytics Clinical Consultant
EXL Health Analytics Pvt Ltd
01.2023 - Current
- Healthcare Business consulting, Solution Design and support functions
- Subject Matter expert in supporting the deployment and effective use and future development plans for healthcare FWAE (fraud waste abuse and error) solution
- Support Product Innovation team who builds products - Automating policies, and contracts, NLP- AI Assisted- Medical Records Audit, GEN AI Newsletter research use case to Concept Development Engine CDE, SNOMED CT Algorithm - Outpatient CPT procedures in NLP
- Worked in Power BI to develop and create operational dashboards, client reports, and monthly performance reports. Designed interactive and dynamic dashboards to visualize key performance metrics and enhance data-driven decision-making. Automated reporting processes to improve efficiency and accuracy. Integrated data from multiple sources to generate comprehensive insights for stakeholders. Collaborated with cross-functional teams to refine dashboard functionalities and ensure alignment with business objectives
- Contributed to the program team's concept creation by creating and refining concepts, integrating new insights and strategies based on recent trends and findings in healthcare fraud from OIG, Justice.gov, and similar outlets
- Collaborated with Onshore and Offshore Subject Matter Experts to address discrepancies in concepts
- Tracked and updated daily work status in DevOps, ensuring transparency and workflow efficiency. Collaborated with teams to resolve bottlenecks and maintain smooth sprint progress
- Conducted regular reviews of the program monitoring report to track the performance of specific concepts
- Provided recommendations for enhancing or closing concepts based on report findings
- Training sessions on payment integrity for new Vice Presidents and Assistant Vice Presidents in the organization
Lead Assistant Manager - Healthcare Operations
EXL Health Analytics Pvt Ltd
02.2021 - 12.2022
- Directed a team of 20+ members, ensuring high productivity, Quality assurance and TAT
- Outpatient auditing for ASC and APC client coding with extensive experience from multi specialty including Integumentary, Orthopedic, Musculoskeletal, spinal procedures, CVIR, EDEM, Genitourinary, Gastrointestinal procedures including all scopies, Ophthalmic and ENT, Radiology procedures
- Maintain and Manage client SOPs for audit instructions
- Managed monthly and weekly reporting decks and quality dashboards, tracking key performance metrics
- Oversaw monthly projection planning, setting individual and team targets, and implementing a daily client reporting system
- Developed training programs to enhance team skills and performance and created learning materials
- Monitored live transactions, conducted audits, and prepared analysis reports, providing feedback, and tracking progress.
- Actively participated in recruitment, assessing candidates' skills and potential, and onboarding top talent for the process.
- Drove individual development plans (IDPs), gauging associates' learning needs, and supporting their growth.
- Led early discussions to mitigate attrition and retain key resources within the team.
- Collaborated with onshore and offshore teams to resolve client escalations and maintain process efficiency.
Quality Lead – SME
EXL Health Analytics Pvt Ltd
11.2018 - 01.2021
- Directed a team of senior QA professionals with subject matter expertise
- Supervised the team's quality, conducted training sessions, and facilitated monthly Knowledge Assessment Tests (KAT) to evaluate the team's understanding and retention of key concepts
- Maintained Standard Operating Procedures (SOPs) for all levels of the audit process
- Conducted quality audits and reviews, ensuring compliance with industry standards.
- Implemented process improvements to streamline operations and enhance service delivery.
- Conducted quality and retrospective audits across multiple domains, including Surgery, Clinical, Pharmaceuticals administration, High Cost Drug Audit (HCD), Durable Medical Equipment (DME), Evaluation & Management (E/M), Emergency Department (ED), Ambulatory Payment Classification (APC), Diagnosis-Related Group (DRG), and outpatient audits through proactive self-learning.
- Proficient in using coding tools such as 3M, Encoder, and PAREO
SME – Medical Audit
EXL Health Analytics Pvt Ltd
03.2017 - 11.2018
- Peer Clinical Review – Responsible for approving or declining claims and authorizations by applying utilization management principles in alignment with Medicare, AAPC, and CPT Assistant coding guidelines
- Conducted monthly Knowledge Assessment Tests (KAT) to keep the team updated on evolving guidelines
- Provided clarifications through daily huddles and escalation calls to address updates, feedback, and ensure accuracy and efficiency
- Led weekly training sessions on client updates to enhance team competency
Senior Quality Analyst- Medical Coding
Omega Healthcare Management Services
12.2011 - 09.2016
- Accurately assigned ICD-9-CM and/or CPT codes to sequence diagnoses and procedures based on patient medical records
- Audited and ensured the assignment of complete, accurate, timely, and consistent codes by the medical coding unit
- Reviewed clinical notes, patient encounter forms, and health information for compliance with HIPAA regulations and coding standards
- Provided coding and documentation guidance to the coding unit, clinical staff, and other healthcare professionals
- Analyzed billing data to improve coding accuracy and ensure compliance with Medicare reimbursement guidelines
- Ensured coded data accurately reflected the services provided, preventing fraudulent claims and billing errors
- Conducted training sessions, in-service programs, and other educational initiatives on diagnosis and procedure coding, as well as regulatory requirements
- Trained new hires and conducted weekly assessments for the team to ensure alignment with client specifications
- Participated in client communication calls to clarify queries and enhance understanding of client expectations
- Actively participated in CPR (Red Alert) calls for client escalations, providing strategic insights to resolve critical situations
- Played a key role in retaining high-priority projects (ARM, HBR) within the organization
Senior Transaction Processing Executive/Coding
Dell international services
03.2009 - 06.2011
- Coded for Radiology, Surgery, Evaluation & Management (E/M), and Emergency Department (ED) services, providing appropriate diagnostic and therapeutic procedure codes using CPT and ICD
- Followed hospital coding guidelines and regulatory rules to ensure accurate coding decisions
- Reviewed and abstracted relevant clinical data from medical records to select and sequence the appropriate ICD-9-CM diagnosis codes
- Analyzed claim denials and identified appropriate solutions by providing Denial Management services and accurate coding
Trainee Coder
Ajuba Solutions
03.2008 - 02.2009
- Trained as a Professional Medical Coder, gaining foundational knowledge in medical coding
- Worked as a Trainee for six months, in addition to completing 45 days of formal training, and received GOLDEN STAR Awards for outstanding performance during the training program
Education
Bachelor of Physiotherapy (BPT) - Physical Therapy
The Tamil Nadu Dr.M.G.R. Medical University
01.2008
Skills
- Healthcare fraud detection
- Team Leadership
- Medical Coding Expertise
- Client Relationship Management
- Process Improvement
- Multispecialty Payment Integrity Medical Audit Subject Matter Expert
- Medicare auditor
- Business Analysis
- Power BI
- Basic SQL
- MS Excel
- AHIMA-Certified ICD-10-CM Educator
- Fast learner
- ISO 2008-certified compliance auditor
Accomplishments
- Awarded 'Fast Learner' for exceptional learning agility, quickly mastering evolving industry standards and guidelines.
- Achieved 'Best Quality Leader' recognition for mentoring the team, optimizing audit processes, and maintaining top-tier quality standards.
- Twice awarded the 'Human Ingenuity Awards' in Q2 2022 for outstanding contributions in both Onshore and Offshore categories, showcasing adaptability and innovation.
- · Awarded 'Best Support Employee of the Quarter' in 2021 for collaborating with the Global NLP team, providing clinical SME insights for text parsing, keyword extraction, and rule-based automation. Played a key role in enhancing machine interpretation of medical documentation, as well as contributing to medical record mapping and page indexing.
Languages
English
First Language
Tamil
Proficient (C2)
C2
Certification
- CPMA, 2018
- CPC, 2014
- MDAM,2009
- BPT, 2003-2008
Timeline
Manager- Business Analytics Clinical Consultant
EXL Health Analytics Pvt Ltd
01.2023 - Current
Lead Assistant Manager - Healthcare Operations
EXL Health Analytics Pvt Ltd
02.2021 - 12.2022
Quality Lead – SME
EXL Health Analytics Pvt Ltd
11.2018 - 01.2021
SME – Medical Audit
EXL Health Analytics Pvt Ltd
03.2017 - 11.2018
Senior Quality Analyst- Medical Coding
Omega Healthcare Management Services
12.2011 - 09.2016
Senior Transaction Processing Executive/Coding
Dell international services
03.2009 - 06.2011
Trainee Coder
Ajuba Solutions
03.2008 - 02.2009
Bachelor of Physiotherapy (BPT) - Physical Therapy
The Tamil Nadu Dr.M.G.R. Medical University
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