Reshma Suresh Gouli
Bengaluru
Summary
With eight years of comprehensive experience in the U.S. In the healthcare domain, I possess in-depth expertise in claim processing and a thorough understanding of medical terminology, including procedure codes, diagnosis codes, medical records review, provider information, and claim status. My proficiency also extends to benefit coding and configuration. Currently serving as a Business Analyst, I bring strong domain knowledge and analytical skills to drive effective solutions.
Overview
8
8
years of professional experience
Work History
Business Analyst
Carelon Global solutions
Bengaluru
12.2019 - Current
- Experience in the end-to-end healthcare claims lifecycle, from submission to adjudication, and reimbursement.
- I worked in the benefit adjudication and coding team, ensuring backend processing and accurate coding of benefits before UAT testing.
- Deep understanding of payer-provider interactions, claims submission, and reimbursement processes, along with EDI transactions (837/835, 834, 270/271, 277). As part of the benefit validation and testing team.
- Strong understanding of medical terminology and work experience on Medicare and Medicaid reimbursement policies.
- Experienced in validating benefit changes via UAT, and regression testing to ensure accuracy and compliance.
- Skilled in collaborating with teams to document requirements, create user stories, and optimize workflows.
- Skilled in creating BRD and FRD, translating business needs into clear, functional requirements.
- Applied Agile methodology, coordinated with vendors for issue resolution, and addressed post-production plan design amendments through retesting.
- Have a working knowledge of AI and machine learning integration, and web application development for enhancing healthcare solutions and automation.
- Conducted interviews with subject matter experts to gather information on existing systems and procedures.
- Presented complex technical concepts in clear manner suitable for non-technical audiences.
- Provided technical support during user acceptance testing cycles.
Associate Consultant
UST GLOBAL TECHNOLOGY SERVICES
Bengaluru
09.2018 - 12.2019
- Skilled in benefit configuration, ensuring accurate plan setup, validation, and compliance with payer policies and regulations.
- Configured provider pricing and maintained the network, ensuring competitive and up-to-date rates.
- Reviewed 270 eligibility requests and 271 responses to verify member benefits, coverage details, and payer information accuracy. (Aces Blue Exchange Process.)
- Created and verified member eligibility, ensuring accurate and efficient processes.
- Successfully managed process transitions and conducted effective training for smooth knowledge transfer.
Process Associate
Hinduja Global Solutions (HGS)
Bengaluru
03.2017 - 09.2018
- I worked in medical claims billing, submission, and reimbursement processes across Medicare and Medicaid.
- Process CAS Prepay - Part of the medical billing process, auditing, and thoroughly investigating claims from initiation to completion, ensuring accuracy before provider payment.
- Determined provider payment based on contractual terms or letters of agreement, adhering to claim-specific scenarios
- Identifying and resolving claim denials, rejections, and resubmissions to optimize revenue cycle performance.
Education
B.Com - Commerce
Dharwad University
Dharwad05-2016
Skills
- Work experience in claims adjudication, benefit adjudication, benefit coding, and configuration, along with member enrollment knowledge
- Claims processing, billing, and reviewing ICD codes and procedure codes
- HIPAA compliance
- UAT (User Acceptance Testing)
- SQL
- Excel, PowerPoint, Word
- BPMN
- Visio
- Requirement Gathering
- Requirement Analysis
- Business Requirement Document Creation
- Good communication and stakeholder management skills
Languages
- English
- Kannada
- Hindi
Total Work Experience
8 Years 0 Month
Accomplishments
• 1 Top Gun award (for the top productions in the project)
• 1 Best Mentor Award
More than eight impact awards
Awarded for making an impact for good performance
Received the client’s appreciation for completing the high-priority group testing within TAT, with 100% accuracy
Received the Best Performer award, making an impact on training the new joiners
Affiliations
• Expertise in benefit configuration, benefit validation testing, and PDM.
• Responsible for exceeding the client standard and accuracy of 99.99% and above consistently.
• Responsible for driving the team to meet daily capacity and worked as backup for the SME
• Solving queries for team members on time and providing floor support/Supervision.
• Conduct Root Cause Analysis of the error received by the team and provide feedback to maintain high-quality service.
• Identify and raise issues proactively and schedule the discussion with the Client.
• Identify and raise issues proactively and schedule the discussion with the Client.
• Conduct team huddles/meet to identify any process updates.
• Production Planning (Work distribution and back up)
• Performed internal auditing to make sure that the members were compliant with the controls.
Timeline
Business Analyst
Carelon Global solutions
12.2019 - Current
Associate Consultant
UST GLOBAL TECHNOLOGY SERVICES
09.2018 - 12.2019
Process Associate
Hinduja Global Solutions (HGS)
03.2017 - 09.2018
B.Com - Commerce
Dharwad University
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