Sanjaya Kumar Patro

Process overview: Streamlined advanced home delivery system for prescription medication access, enhancing convenience and reducing costs.

• Led three Scrum teams to optimize pharmacy home delivery processes.
• Guided Agile planning and tracking while providing coaching to team members.
• Fostered collaboration through Scrum of Scrums and PI calls.
• Oversaw coordination for seamless production deployment across multiple teams.
• Ensured stakeholder alignment through strategic communication initiatives.
• Tracked sprint performance metrics, identifying areas for future improvement.
• Created dashboards using JIRA, Confluence, and Trello to monitor project progress.

Process Overview: Pharma benefit configuration defines and manages pharmaceutical coverage within a health insurance plan, ensuring proper setup and administration of benefits.

• Lead a team of 43 associates in pharmaceutical benefit configuration and quality analysis.
• Guide junior analysts and coach teams in data analysis and project management.
• Translate business requirements into system specifications.
• Optimize benefit plans through cost and usage analysis.
• Drive continuous improvement initiatives.
• Manage timelines, budgets, and resources.
• Ensure stakeholder alignment and risk mitigation.
• Oversee testing and execution of benefit updates.
• Pharma benefit configuration defines and manages pharmaceutical coverage within a health insurance plan, ensuring proper setup and administration of benefits.

Process Overview: Offering data-driven insights to healthcare administrators by analyzing claims data, identifying trends, and recommending solutions to enhance operations, patient care, and compliance.

• Extract insights from healthcare claims data to recommend improvements and support decision-making.
• Implement systems and strategies to optimize data quality.
• Assess the impact of healthcare policies and regulations on service delivery.
• Create detailed reports of findings, and present them to management.
• Work with IT professionals to coordinate system updates and improvements.
• Ensure compliance with federal, state, and local data privacy regulations.
• Assist in budget preparation and financial planning through trend forecasting.
• Train and mentor junior staff in complex administrative tasks.
• Lead team meetings and discussions to enhance productivity and efficiency.
• Oversee special projects, and ensure their successful completion.
• Offering data-driven insights to healthcare administrators by analyzing claims data, identifying trends, and recommending solutions to enhance operations, patient care, and compliance.

Process Overview: Handles member and provider appeals for State Health Plans by reviewing, forwarding, and resolving cases appropriately.

• Lead a team of 32 agents in provider, member appeal, and grievance processes.
• Initiated automation projects by collaborating with IT and management.
• Enhanced team accuracy and efficiency through automation and Lean initiatives.
• Foster a positive work environment, reducing attrition, and boosting morale.
• Mentor, support, and develop team members while resolving queries.
• Oversee and optimize shift operations for a seamless workflow.
• Handles member and provider appeals for State Health Plans by reviewing, forwarding, and resolving cases appropriately.

Process Overview: The process focuses on validating medical insurance plan outcomes by tracking expected results and ensuring accuracy.

• Validate the expected benefit grid results from the plan data.
• Test claims to ensure accurate payment processing.
• Perform comprehensive test case evaluations before the plan launch.
• Verify medical, hospital, dental, and vision claims.
• Analyze plan benefits, and configure mainframe coding for accuracy.
• Develop mainframe macros to enhance speed and precision.
• Conduct internal audits to validate expected vs. Actual outcomes.
• The process focuses on validating medical insurance plan outcomes by tracking expected results, and ensuring accuracy.

Process Overview: Process and calculate benefits for members and providers, while ensuring high-quality claim processing and confidentiality in payments.

• Process professional, institutional, Medicare, and Medicaid claims.
• Calculate benefits based on criteria and provider contracts.
• Identify authorizations and match them to claims.
• Interpret health plan financial responsibilities and contract terms.
• Determine provider network status, and ensure compliance.
• Process claims accurately, meeting quality, and timeliness standards.
• Support special projects, and develop macros for efficiency.
• Process and calculate benefits for members and providers, while ensuring high-quality claim processing and confidentiality in payments.