Soumya Varthan Gunda
Hyderabad
Summary
Dynamic Clinical Fraud Investigator with expertise in claims review and CPT coding at Optum Global Solutions. Proven track record in clinical data analysis and internal auditing, fostering team collaboration and enhancing service delivery. Adept at preventing fraudulent claims while building strong customer relationships and driving operational excellence.
Overview
15
15
years of professional experience
Work History
Clinical Fraud Investigator
Optum global solutions (United Health Group)
Hyderabad
12.2018 - Current
- Company Overview: Mindspace, Hyderabad.
- Payment & Integrity (Employee and individual - Clinical First review and Recons in Inpatient, Outpatient, ED, Labs, Surgical) United states Health care
- Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies
- Department- FWAE PRSPTIVE & TRIAGE OPTUM
- Clinical data reviewer – Inpatient, Outpatient, ED, Labs, Surgical
- Mentor
- Internal auditor
- Trainer
- SME
Asst Manager – Customer care Operations
Vijaya Diagnostic center Pvt Ltd
Hyderabad
01.2015 - 12.2018
- Company Overview: (India’s largest comprehensive medical diagnostic center)
- Project Lead - Home Health / Business Development
- Duration: January 2018 December 2018.
- Project Lead- Customer Services/ Customer Feedback
- Duration: January 2017- December 2018
- Patient relations
- 2015 January -2016 December
Asst nursing superintendent
Yashoda Multi specialty Hospital
Hyderabad
07.2014 - 09.2014
Registered Nurse
Yashoda Super specialty Hospital
Hyderabad
02.2010 - 07.2012
Education
MBA - Hospital and Healthcare Management
Apollo Institute of Healthcare Management (AIHCM)
Hyderabad, India01.2014
Bachelor’s - Nursing
Yashoda College, Dr.N.T.R University of Health Science
Hyderabad, India01.2009
H.S.C -
Vishvodaya junior college
Nizamabad, India01.2005
S.S.C -
Vijay public school
Armor, India01.2003
Skills
- Clinical data analysis
- Claims review
- CPT coding
- Team Building
- Business analysis
- Data Analysis
- Insurance fraud
- Service delivery support
- Internal auditing
- Excellent Communication skills
- Analytical skills
- Employment Training & Development
- Profit and loss analysis
- Strategy management
- Data Management
- Customer Relationship building
- Workflow planning and prioritization
Languages
Fluent in English, Hindi, Telugu, Malayalam.
Projects
Part of One click application development as a user end tester 2025, E&I clinical- Enhance routing and work prioritization testing (Optum) 2022 E&I clinical- Enhance routing and work prioritization testing (Optum) 2022, Home sample collection Services/ Business Development 2018, Establishment of Centralized Call Centre 2017- Customer support services, Turnaround time of logistics in laboratory services 2015- Providing the Lab reports within the give time, Material Management” 2013 – Identifying the misusage of Materials (Medical & Surgical), Hands-off time in nursing” 2014, Medical Record Auditing (Internal) 2013, Time Management in Discharge Process 2011, Project on Diabetic Care management” 2009.
Training
- World Health Conference on Patient Safety”, Apollo Hospitals, Hyderabad, 2005.
- Holistic Health Conference for Nursing on “Caring, Sharing, Inspiring Core Values for Better Nursing Care 2009 at Brahma Kumaries, Shantivan, Mt. Abu Road (Rajasthan) India.
- Basic Cardiac Life Support, ACLS, Teamwork and Silent Skills, Fire and Safety Management”, Yashoda Hospital, Malakpet, Hyderabad, 2010-2012.
- Workshops on Alternative Feeding Methods” Johnson& Johnson Company, 2010
- International Congress on Patient Safety”, Apollo Hospitals, Hyderabad, 2012
- Transforming Health Care into It”, Apollo Hospitals, Hyderabad, 2013
Computer Proficiency
- MS office [word, excel, power point]
- Operating system: Windows 10
Core skills
- Good team building attributes with strong leadership and motivational abilities.
- An adaptive learner and receptive to feedback, always looking to improve the process.
Timeline
Clinical Fraud Investigator
Optum global solutions (United Health Group)
12.2018 - Current
Asst Manager – Customer care Operations
Vijaya Diagnostic center Pvt Ltd
01.2015 - 12.2018
Asst nursing superintendent
Yashoda Multi specialty Hospital
07.2014 - 09.2014
Registered Nurse
Yashoda Super specialty Hospital
02.2010 - 07.2012
MBA - Hospital and Healthcare Management
Apollo Institute of Healthcare Management (AIHCM)
Bachelor’s - Nursing
Yashoda College, Dr.N.T.R University of Health Science
H.S.C -
Vishvodaya junior college
S.S.C -
Vijay public school
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