Summary
Overview
Work History
Education
Skills
Objective
Timeline
Generic
Lokesh S

Lokesh S

Bangalore

Summary

Dynamic Senior Associate with extensive experience in claims adjudication at Carelon Global Solutions. Proven track record in mentoring teams and developing SOPs, enhancing quality assurance, and driving operational efficiency. Skilled in internal auditing and fostering collaboration, resulting in improved performance metrics and compliance with industry regulations.

Overview

8
8
years of professional experience

Work History

Senior Associate - US Healthcare Operations -Claims

Carelon global solutions
11.2018 - 03.2024
  • Managed and lead a team of 20 claims processors, ensuring timely and accurate adjudication of healthcare claims in compliance with client-specific payor guidelines and industry regulations (HIPAA, CMS).
  • Monitored individual and team KPIs including turnaround time (TAT), accuracy, productivity, and quality; conducted daily huddles, performance reviews, and implemented action plans for continuous improvement.
  • Ensured adherence to client SLAs and internal quality standards through regular audits, error trend analysis, and corrective action plans, minimizing rework and claim rejections.
  • Delivered process-specific training and refresher sessions; mentored new hires and cross-trained team members to enhance team versatility and efficiency.
  • Acted as the point of contact for client escalations and process updates; provided regular MIS reports, RCA for escalations, and participated in client calls and audits.
  • Designed and delivered structured training programs for new hires and cross-functional team members in US healthcare claims adjudication processes, policies, and compliance standards.
  • Conducted regular refresher sessions and updates on process changes, client-specific requirements, and regulatory updates (HIPAA, CMS).
  • Mentored and coached team members to improve accuracy, productivity, and overall performance; facilitated continuous learning through on-the-job training and knowledge-sharing sessions.
  • Created training manuals, SOPs, and process documentation to support standardized learning and quick onboarding.
  • Lead performance gap analyses to identify training needs and implemented skill development initiatives aligned with process goals and quality standards.
  • Developed, reviewed, and maintained Standard Operating Procedures (SOPs) for end-to-end US healthcare claims processes, ensuring alignment with client requirements and regulatory compliance (HIPAA, CMS).
  • Led periodic audits and updates of SOPs to reflect process enhancements, policy changes, and automation updates.
  • Collaborated with quality, compliance, and operations teams to ensure SOPs support training, performance monitoring, and error reduction.
  • Supported continuous improvement initiatives by integrating SOP revisions based on RCA (Root Cause Analysis), error trends, and feedback loops.
  • Conducted internal quality audits on healthcare claims to ensure accuracy, compliance with SOPs, and adherence to client-specific SLAs and regulatory standards (HIPAA, CMS).
  • Analyses audit findings to identify error trends, process gaps, and training needs; implemented corrective and preventive actions (CAPA) to enhance quality performance.
  • Collaborated with the quality assurance team to develop audit checklists, sampling methodologies, and quality scorecards for performance tracking.
  • Facilitated feedback sessions and coaching with processors based on audit outcomes to drive continuous improvement.
  • Generated and presented monthly quality reports with RCA insights, helping management take data-driven decisions to reduce rework and improve claim adjudication standards.

Business Analyst

Hinduja global solutions
04.2017 - 09.2018
  • Reporting the financial metrics dashboard to the internal management team.
  • Process Metrics review with the senior management and the team.
  • Timely invoicing and reporting of deliverables like Performance Incentive, Internal Dashboards.
  • Coordinate on Process Quality requirements.
  • Manage delivery of quality claims results and daily operations.
  • Identifying, recommending and implementing ways to increase the productivity and the quality of the team.
  • Advice subordinates on technically involved cases (high exposure, questionable coverage situations, suspected fraud, exposures that exceed policy limits, etc.) and extends settlement authority after reviewing claim files.
  • Conduct ongoing inspections of operations to ensure compliance with applicable legislation; technical and administrative objectives i.e., accepted claims handling practices (ISO & HIPAA).
  • Communicate new and revised policies and procedures to personnel.
  • Oversight of recruitment, interviewing and selection of claims personnel; ensure personnel receive orientation initial and ongoing technical training.
  • Effective Resource Utilization.
  • Conduct performance appraisals, identify performance problems and approve disciplinary actions.
  • Implement new and revised policies and procedures; keep employees informed of current company goals and objectives.
  • Control Absenteeism and Attrition in the Process.
  • Meeting SLA’s – DSS Project designing a process, ensuring gaps leading to deep impact error on high weightage stratums.

Operations Claim Processing Executive

Hinduja Global solutions
04.2016 - 04.2017
  • Claim Processing Executive (SP) was responsible for adjudication of claims for HMO plans from specialist or institutional providers and provide mentor support to other CPE.
  • Managing activities pertaining to insurance claim processing involving assessment of validity of claims of various clients, checking on quality parameters etc.
  • Leading a 6 member team.
  • Generating MIS (log file) & reporting the status of claims processed.
  • Handling payments worth approximately 3 million dollars a month.
  • Processing medical and hospital claims submitted by Health care providers in US and adjudication of the same based on available documentation and clinical information available on the online system.
  • The process also caters the task of analyzing medical case history of a patient, analyzing approvals and denials by the medical director (of the health insurance company) for the medical treatment of the patient for a particular ailment or disease.
  • Possess an In-depth knowledge of U.S health care system, HIPAA Regulations, Claim Adjudication, provider contracts, Healthcare State Legislation, Co-ordination of benefits between inter-insurance companies.
  • Identifying and suggesting strategies for building team effectiveness by promoting a spirit of cooperation between team members.
  • Assigning claim cases, monitoring numbers and achievement of overall targets on a daily, weekly & monthly basis in adherence to the pre-set individual standards for tasks up to 2,500 a week.
  • Handled basic and specialty training for several batches ranging from 10 to 20 people.

Education

B.com - computers

S V University
Tirupathi
04-2014

Skills

  • Claims adjudication
  • Mentoring team members
  • Inventory control
  • Quality assurance
  • SOP development
  • Internal auditing
  • Training and mentoring
  • Team supervision

Objective

  • To secure a challenging position that allows me to utilize my skills and experience to drive organizational objectives and contribute effectively to its success.

Timeline

Senior Associate - US Healthcare Operations -Claims

Carelon global solutions
11.2018 - 03.2024

Business Analyst

Hinduja global solutions
04.2017 - 09.2018

Operations Claim Processing Executive

Hinduja Global solutions
04.2016 - 04.2017

B.com - computers

S V University

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