Sameer Shantaram Toke
Senior Analyst
Pune
Summary
Experienced Healthcare IT Professional with 10.5+ years in the US healthcare domain, specializing in claims processing, data management, appeals & grievances, and healthcare analytics. Proven ability to lead funding and recovery initiatives, streamline workflows, and drive performance in high-volume environments. Certified in Power BI Desktop and SQL, with strong analytical and collaborative skills.
Overview
12
12
years of professional experience
2
2
Certifications
3
3
Languages
Work History
Senior Analyst – Funding & Recovery
Evolent Health International Pvt. Ltd.
09.2021 - Current
- Manage funding and recovery processes, including member terminations, overpayments, refund posting, and recoupments.
- Use tools like Pareo, Jira, MPX, and Smart Data Solution for data analysis and tracking.
- Coordinate with clients (Premera, MPC, Bright, Beacon, Empower, Countycare) for fund reconciliation and issue resolution.
- Document and maintain detailed test scenarios and reporting dashboards using Power BI and SQL resolution.
Process Specialist – Aetna Project
Infosys BPM Ltd.
07.2018 - 08.2021
- Audited and analyzed appeals under Medicare guidelines; supported pre/post-service appeals.
- Created performance reports and mentored team members.
- Tools used: CATS, ECHS, IOP, ASD.
Associate – KPO Healthcare
Syntel India Ltd.
08.2016 - 06.2018
- Conducted claims analysis, bug testing, and automation testing for Humana Healthcare.
- Prepared test scenarios and QA reports using tools such as CAS, MTV, and Argus.
- Worked on a claim adjustment project focused on the MOOP (Maximum Out-of-Pocket) process.
- Responsible for handling corrected claims, and ensuring accurate processing.
Associate – Colorado Access Client
Trizetto India Pvt. Ltd.
04.2014 - 07.2016
- Handled AHC claim processing, and escalated claim reviews across multiple queues.
- Processed high-dollar claims using the Microdyn Standalone Pricer.
- Accurately managed both inpatient and outpatient claims.
- Platforms used: QNXT and Microdyn Pricer.
Education
Bachelor of Computer Application - Computer Application
Maharashtra College of Science & Commerce
PuneIntermediate - 12th Grade
P Jog College of Science & Commerce
PuneMatriculation - 10th Grade
Raja Shri Shivray Pratishthan Madhyamik Vidyalaya
PuneSkills
Healthcare IT Applications: CATS, MTV, CAS, ASD, Argus, QNXT, Aldera
Certification
Power BI Desktop – Completed
Accomplishments
- Spot Recognition Awards – Evolent Health (2022, 2023,2024,2025)
- Best Performer Award – Infosys BPM
- Adaptive Award (Q4 2017) – Syntel India (20% productivity gain)
- Cricket Champion – Winner in multiple corporate tournaments at Trizetto, Evolent
Core Competencies
- Claims Adjudication
- Appeals & Grievance
- RFF Activity (Request For Fund)
- Refund & Payment Posting
- Member Termination
- SDS(Smart Data Solution)
- Funding Queue
- Claim Adjustment & Corrected Claim
- Overpayments & Recoupment
- Data Analysis & Reporting (Power BI, SQL)
- Healthcare IT Systems (CATS, MTV, ASD, CAS, QNXT, Aldera)
- ERP & Workflow Tools (Pareo, Jira, Smart Data Solution, MPX)
- Testing & Scenario Creation
- Cross-functional Team Collaboration
- US Healthcare Regulations & Processes
Strengths
- Strong analytical and organizational skills
- Highly collaborative and adaptive to change
- Excellent attention to detail and problem-solving ability
- Positive, respectful, and professional work ethic
Personal Details
- Date of Birth: 1989-09-11
- Marital Status: Married
- Address: Flat No 10, Indranil Galaxy, Shindenagar, Bavdhan, Pune 411021
Timeline
Senior Analyst – Funding & Recovery
Evolent Health International Pvt. Ltd.
09.2021 - Current
Process Specialist – Aetna Project
Infosys BPM Ltd.
07.2018 - 08.2021
Associate – KPO Healthcare
Syntel India Ltd.
08.2016 - 06.2018
Associate – Colorado Access Client
Trizetto India Pvt. Ltd.
04.2014 - 07.2016
Bachelor of Computer Application - Computer Application
Maharashtra College of Science & Commerce
Intermediate - 12th Grade
P Jog College of Science & Commerce
Matriculation - 10th Grade
Raja Shri Shivray Pratishthan Madhyamik Vidyalaya