Raghu Ram Pilaka
Visakhapatnam,AP
Summary
Over 9.8 years of experience in the US healthcare industry, including 7.8 years of functional expertise and 1.8 years of IT techno-functional experience. EHR, PM, patient portals, system administration, EMR, EDI, encounters, and 837P&I submissions are the main areas of expertise. Additionally, it adds a great deal of value to be proficient in SQL for query writing and table creation, as well as business intelligence tools like Excel and Power BI.
Overview
11
11
years of professional experience
Work History
Sr.Quality Analyst
Carelon Global Solutions(Simplify3x) Cont.
11.2022 - 07.2024
- Experience in Nextgen EHR Enterprise, Practice Management, Provider Management, File Maintenance.
- Experience in Electronic data Interchange review, EDI Submissions, 837 Professional and 837 Institutional Submissions.
- Proficiency in Health care application – NextGen, Tidal Jobs, Claims, Encounters, Memberships, Providers and basic knowledge about Mirth Connect and HL7 Integration Systems and SQL.
- Worked with Product Owners in gathering the story requirements for the User Stories using JIRA and in discussing the prioritization of the backlogs.
- Gathering the validation Activity requirements from business requester's and Software design specifications from the developers and make sure that validation passed in each and every stage of the testing including Dev and STG along with the final testing stage of User Acceptance Testing.
- Worked on Claims and Encounters inbound and outbound processes along with Providers and Membership modules.
- Helping DEV teams with the necessary changes of the EHR custom template Information.
- Actively participated in the P.I Planning and Implementation meetings, Dependency, daily standup's, Sprint planning and Backlog reviews.
Remote Medical Coder
Clinic Anywhere
07.2019 - 11.2022
- Worked as a coding specialist on internal medicine and family medicine, along with multi-specialty practices, along with physician billing, billing rejections from the payor end, and handling internal rejections.
- Worked on complete provider end and payer end rejections as per the client updates by maintaining TAT to send out claims on time.
- Proficient in RCM, patient administration systems, and assigning appropriate ICD-10, HCPCS, and CPT codes for diagnosis treatments into appropriate coding/billing systems.
- Reviewing complete patient encounter data to verify the chief complaint and treatment-based complaints.
- Handling denial issues on the working specialties by maintaining a 24-hour TAT
Transitioned hospital & provider-side US-based healthcare insurance charge entry process. - Reviewing the complete PDF charts produced by office physicians for a clear understanding of coding the procedures and mapping the diagnosis part
- Hands-on experience in handling multi-specialty coding and also handling more than 12 coding clients and performing coding and completion of claims to payers in a turnaround time and updating pending coding escalations to client reports daily.
- Working on New Birth Client Support with the motive of reviewing EHR and EMR systems as per documents provided by physicians.
- Resolving E/M coding rejections and submitting them back to the insurance.
- Reading and analyzing patient records as per insurance guidelines by proceeding with the claims submissions and process and also determining the correct codes for patient records, also using source codes to bill insurance providers.
Senior Medical Billing Specialist
Cerner Corporation
10.2018 - 06.2019
Senior Associate
Getix Health LLC.
01.2016 - 09.2018
Associate
Xerox Corporations
08.2015 - 12.2015
Associate
Scitus Labs & Technologies
06.2013 - 09.2014
Education
Bachelor of Computer Applications - Computer Science
Manav Bharti University
2013
Skills
- Knowledge of the EHR Solution Analysis is one of the main skill sets
- Secondary Skillsets: EDI & 837P, 837I
- Healthcare Databases: NextGen West, AGP, and East DB's SQL Server
- Healthcare worked entities: EHR, EMR, EDI, 837P & 837I, E/M and multi-specialty coding, claims, encounters, benefits, membership, provider claims, and enrollments
- System/Tool Exposure: CERNER Practice Management, CERNER Client EHR & EMR Systems, TriZetto GATEWAY EDI, OPTUM Health, ICD 10 Data, Encoder Pro
- Jira
- Skill Upgrade: Power BI, SQL, Excel
- Certifications: Power BI, Business Analysis, and Excel
Languages
English
Hindi
Telugu
Timeline
Sr.Quality Analyst
Carelon Global Solutions(Simplify3x) Cont.
11.2022 - 07.2024
Remote Medical Coder
Clinic Anywhere
07.2019 - 11.2022
Senior Medical Billing Specialist
Cerner Corporation
10.2018 - 06.2019
Senior Associate
Getix Health LLC.
01.2016 - 09.2018
Associate
Xerox Corporations
08.2015 - 12.2015
Associate
Scitus Labs & Technologies
06.2013 - 09.2014
Bachelor of Computer Applications - Computer Science
Manav Bharti University
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