Summary
Overview
Work History
Education
Skills
Accomplishments
Certification
Languages
Timeline
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Praveen Kumar V

Bengaluru

Summary

Accomplished Senior Associate at Carelon Global Solutions with 5 years of progressive experience in U.S. healthcare claims adjudication. Recognized 13 times for exceptional leadership, process improvements, and consistent high performance. Promoted to Senior Associate in March 2024 in recognition of outstanding performance and dedication. Expert in independently managing complex claims, ensuring compliance with regulatory standards (HIPAA, CMS), and driving operational efficiency. Skilled in training, mentoring, and enhancing team performance while maintaining strong stakeholder communication. Proficient in data analysis, quality assurance, and utilizing multiple adjudication platforms to deliver accurate, timely results. Excellent command of written and spoken English with a neutral accent, committed to client satisfaction and continuous improvement. Currently serving notice period with a proven track record of promotion and impactful contributions.

Overview

5
5
years of professional experience
1
1
Certification

Work History

Senior Associate

Carelon Global Solutions
Bengaluru
11.2020 - Current
  • Evaluated healthcare claim files to determine eligibility under policy guidelines, ensuring accurate and policy-compliant adjudication.
  • Reviewed medical records and claim documents submitted by providers and members to verify accuracy, completeness, and legitimacy of information, identifying red flags or fraudulent activity.
  • Performed in-depth investigations, audits, evaluations, and inspections regarding healthcare delivery and payments, ensuring compliance with organizational protocols and regulatory requirements.
  • Resolved complex provider disputes related to denied or delayed claims, applying policy interpretation and medical necessity criteria to reach fair resolutions.
  • Denied or modified medical authorizations based on investigation findings, including same-day voids and reconsiderations, with full documentation in compliance with CMS protocols.
  • Maintained strict adherence to HIPAA and CMS guidelines in all investigative activities, ensuring the secure handling of Protected Health Information (PHI) and maintaining data confidentiality.
  • Maintained documentation and investigative findings in internal databases while ensuring PHI security, integrity, and limited access per organizational and federal guidelines.
  • Assisted team leads in work allocation, SLA tracking, and queue management, ensuring timely completion of tasks with minimal errors.
  • Trained new hires on internal claims adjudication procedures and company policies, accelerating onboarding and team readiness.
  • Provided on-the-job support and issue resolution for junior associates handling complex or escalated claims.
  • Led process refresher sessions and knowledge sharing activities, improving overall team understanding of updated policies and procedures.
  • Recognized 13 times with the Impact Award by management for consistently delivering exceptional performance, leadership, and contributions to process improvements.
  • Regularly connected with onshore clients to discuss claim-related issues, gather updates, and provide timely resolutions, ensuring alignment with client expectations and process transparency.
  • Analyzed trends in claim data to identify process gaps and implemented changes that improved efficiency and reduced rework.
  • Served as a dedicated team member for the RTM (Real-Time Messaging) project, directly connecting with the Benefit Office to resolve provider queries in real time, significantly reducing turnaround time and enhancing provider satisfaction.

Education

Bachelor of Commerce - Accounting And Finance

The Oxford College of Business Management
Bengaluru
09-2020

Skills

  • Advanced Claims Adjudication & Processing
  • Team Leadership & Mentoring
  • Root Cause Analysis & Problem Solving
  • Regulatory Compliance (HIPAA, CMS, PHI)
  • Stakeholder & Client Communication
  • Process Improvement & Quality Assurance
  • Training & Onboarding Coordination
  • Data Analysis & Reporting
  • Strong Written & Verbal Communication
  • Time Management & Multitasking
  • MS Office Suite (Excel, Word, PowerPoint, Outlook)
  • Real-Time Messaging (RTM) & Issue Resolution
  • Documentation & SOP Development

Accomplishments

  • Impact Award Recipient (13 times) — Recognized by management for consistently delivering exceptional performance, leadership, and driving process improvements at Carelon Global Solutions.
  • Promotion to Senior Associate — Elevated in March 2024 in acknowledgment of outstanding claims adjudication skills, team leadership, and dedication.
  • Consistently Exceeded Accuracy and Productivity Targets — Maintained a claims processing accuracy rate above 98% while meeting or surpassing daily volume expectations over 5 years.
  • Mentorship Recognition — Commended for successfully training and mentoring junior associates, contributing to improved team performance and reduced onboarding time.
  • Key Contributor to RTM Project Success — Played a vital role in real-time provider query resolution, enhancing stakeholder satisfaction and operational efficiency.

Certification

  • Power BI Certification – Demonstrated expertise in data visualization and business intelligence to enhance reporting and decision-making.

Languages

English
First Language
English
Proficient (C2)
C2
kannada
Proficient (C2)
C2
Hindi
Upper Intermediate (B2)
B2
Telugu
Proficient (C2)
C2

Timeline

Senior Associate

Carelon Global Solutions
11.2020 - Current

Bachelor of Commerce - Accounting And Finance

The Oxford College of Business Management

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Praveen Kumar V