Dr Praveen Gvs

                                                      CURRICULUM VITAE                         Dr. V S Praveen Ganapathiraju BHMS, MHA, PAHM, IPGD (LI), CSA, CSSA, CPBA, PSM, PSPO Email:-           Mobile: - Objective A seasoned, dynamic healthcare professional with overall 10 years of experience amongst which the initial 6 years are into pure health care and health insurance and the recent 4 years are into healthcare IT. Experienced in: Healthcare IT: Pega tool, Business requirements gathering, requirements elicitation, Epic grooming, use case creation, user story creation, agile, scrum, SDLC, Testing, product demoes, liaising with stakeholders, conducting DCO sessions etc. Health Insurance: Medical claims adjudication, end-to-end revenue cycle management, claim processing, adjustments, medical coding, medical review, appeals management, denial management, reconciliations, escalations, underwriting, auditing, medical analysis, business analysis, medical and process related training, provider relations, client relations, team correspondence etc. Intend to build a career with committed & dedicated people, which will help me to explore myself fully and realize my potential. Willing to work as a key player in a challenging & creative environment where I can use my skills to manage a team to contribute to the overall success of the organization. Professional Experience: Pega systems Worldwide India Pvt Ltd. Senior Pega Business Process Developer- Healthcare Industry Applications (June 2016- Till Date) Product- Smart claims Engine As a Senior Pega Business process developer in Healthcare, I carry a robust experience of nearly 10 years into US healthcare claims adjudication, claims operations, reporting for analysis, Business analysis etc. which help my knowledge and experience in building a next gen futuristic claims engine for auto-adjudication of the US healthcare claims. As a senior Healthcare Business analyst, I have good knowledge of X12 transactions, EDI, XML, API and how the claims can be ingested through these channels Good knowledge of 837, 835, 834, 276, 277 etc. healthcare X12 transactions. Though a part of claims adjudication engine team, I work with cross- functional teams like PFHC (Pega foundation for healthcare) where the whole foundation data model for the healthcare is built. Good knowledge on data model of Member, provider, provider contract, member contract, authorizations, Business entity, practitioners, policy, provider networks, subscribers, dependents and how they all are interdependent and interlinked. The product being developed is extensive, end-to-end having all the capabilities to auto-adjudicate the claims minimizing the manual intervention. Worked and implemented industry leading functionalities like duplicate claim check identification, auto-identification of hospital readmissions, identifying and handling NCCI edits, identifying and handling interim claims etc. Worked and implemented an industry leading and challenging guided event resolution flow for smart resolution of event codes raised as part of adjudication. As a Sr. Pega BPD, I have good idea of using the Pega tool capabilities to design, build, develop and test the applications being developed. As a Senior BPD, my role is involved in requirements gathering, elicitation, proxy product owner for the owned Epics, coordinating with clients and stake holders for clarity of the requirements. Epic and story grooming with PO's and with internal team mates. US creation, Epic updates, adding the exact acceptance criteria for the Dev team to understand and deliver the exact output required for the story. UAT and functional verification. I have basic knowledge of Pega tool and how to configure things in Pega. Basic debugging with clipboard and tracer tools. Routing work objects to workbasket then to worklist and assigning service levels in the SCE application. Extensively involved in implementation of effective requirements practices, including gathering User Requirements, and analysing User Requirement Document (URD), and functional specification document (FSD), use and continuous improvement of a requirement gathering processes. Actively involved in performing gap analysis as what is missing in the application compared to the industry standards. Involved in designing & determined 3-tier architecture for the claim processing system. Assisted team lead in developing Requirements Traceability Matrix (RTM) to trace the relationship between business and functional requirements to test cases. Prepared and executed different Test Cases. Doing impact analysis of any design on the existing implementation proposed by the architect or dev team to prevent future Documented Meeting Minutes after requirement gathering sessions and distributed to all stakeholders Triaging of the bugs being raised by the dev team to check whether they are valid or not and route to the QA if they are valid. Act as a barrier between the Dev and QA teams for reviewing and analysing the bugs. Participated in bug bash sessions of other healthcare apps and provided them feedback on the healthcare functionality and raised concerned bugs thus improving the quality of those apps. Solid understanding of all phases of Software Development Life Cycle (SDLC) methodology (such as requirement, analysis, design, data modelling, business process modelling, implementation and deployment). Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment). Well versed with HIPAA, Facets, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions. Created flow charts, mock ups for process flows and use cases to make the team easily understand the actual functional requirements. Conducting DCO sessions and updating requirements and specifications in Pega tool. Using agile studio and Pega agile work bench to track all the drum activities. Involved in US sizing using tools like planning poker. High level estimates of the Epics during plan review and detailed Epic estimates during BCR. As I am a part of agile team, I will be taking up of all the necessary activities like bug validations, bug fixing, unit testing, regression testing, sanity testing, system testing especially during the release time. I am a part of scrum team where I will be involved in sprint planning, product back log grooming, sprint back log grooming, user story updates, follow up with PO's regarding the clarity on the requirements. will be part of functional verification of stories once delivered by the Dev team. will be part of sprint reviews, sprint retrospectives, release retrospectives. As a BPD cum proxy PO, I will be responsible for interim demos as well as final demos to all the stakeholders who are interested in adapting and consuming the product being delivered. Functional documentation of the whole epic being delivered to a client. Assist QA team in creating and review of the test cases for any of the functional stories. Do market research as to compare our existing products with those already in market and in developing stage to check what better product can be made and what functionalities that can be incorporated in to our product. Global Benefits Group India Pvt Ltd. Medical reviewer (Dec 2014- June 2016). End to end process knowledge in health claim adjudication, underwriting, appeal decision making, and denial management. 4 years of experience as an international Claim Adjudicator (International claims) Commendable knowledge in processing of US health claims (HCFA, UB) complying with HIPAA standards. Experience as mediclaim auditor. Experience in health underwriting based on the medical history, vitals and risk factors. Experience in judging the insurability of the insured as per the underwriter requirements. Sending underwriting reviews to offshore team on huge dollar claims for finalizing the case and related claims and preparation of reserve amounts. Experienced in training the team on medical and process related queries aiming in process improvement. Conducting PKT (Process improvement knowledge tests) to examiners for betterment of claim adjudication process. Working on appeals of all levels related to medical and process oriented and reverting them on timely manner. End to end process knowledge from claim ID generation through adjudication through audit through payment release through appeal decisions and case closure. As a medical review I will be running high dollar claims report and deliver the status of pend/hold/closed and processed high dollar claims on weekly basis. Sending monthly reports of claims processed to the external clients and offshore team and coordinating with them to close the ageing cases ASAP. Works monthly on the data analysis of the policies and update the team regarding the process deviations. Mainly concentrates on the audit part especially all the high dollars claims and publish the audit report highlighting the examiner errors. Experience is adjudication of member, provider, HCFA, UB claims. Mail communication with customer service team, external clients, offshore team and examiners regarding the medical queries and also process related queries like policy benefits, co-pays, deductibles, coinsurance, etc. Analysis on HCFA, UB claims regarding the ICD codes billed, their pointers, the services rendered and modifiers and helping the examiners on easy adjudication regarding what services to be processed for which DX codes and the pointers tagged. Answering provider and member queries regarding the denial management. As a medical reviewer, my main task is on medical analytics and emphasizing on the process lacuna and at what part of the process the examiners are conducting more mistakes and errors and inform my manager to take necessary steps and training practices to minimize the errors and improve the process/productivity outcome. Correspondence with examiners regarding their queries on timely manner. Good knowledge in ICD-9, CPT, HCPCS coding. Tech Savvy in using outlook, excel and word. Global Benefits Group Senior International Claims Examiner (Dec 2013 - Nov 2014) Processing and adjudication of medical claims Outstanding knowledge of claims processing and medical terminology Superb data entry skills with high accurateness Strong written and spoken communication skills Good computer skills Accurately evaluate, regulate, and pass judgment of Mediclaims in a timely manner Research and take action in response to telephone and written inquires Enter and check over claims into system Send system generated letters to providers knowledge of insurance and accounting procedures and pertinent computer software Excellent communication skills. SAT (Simple, Accurate, Timely) MED CLAIM SERVICES SATMED is the BPO set up newly by the Middle east TPA, WAP MED, a joint venture by the Warba & Apollo group and is spread over 4 Middle East countries. Senior Medical Officer (July 2012- Dec 2013) Medical scrutiny of the Middle East claims. Experienced in processing of direct billing, Reimbursement & cashless claims. Knowledge in scrutinizing Kuwait, Dubai & Abu Dhabi claims. Experienced in ICD & CPT coding. Auditing of the claims scrutinized by medical team. TOB (Table of benefits) preparation and updation. Commercial and medical audit of the claims showing the final impact to the company because of the errors done. Processing and audit of both IG (Interglobal) & Non IG claims. Escalation handling, query resolution in stipulated TAT. Settlement of Resubmission claims. E claims handling from Dubai & Abu Dhabi. Giving appropriate reasons for the dis allowances done. Well versed in the process flow of the entire claim settlement right from claim ID generation through processing, scrutiny, audit to final payment request. Pre-authorization: Revert on cases brought to attention of medical management within TAT Closure on pre-authorization subject to availability of complete information within TAT. Provide inputs for getting appropriate details required for pre-authorization Medico-technical inputs: Patient education as requested Technical inputs for query resolution where requested Other deliverables: Health and Well-being proposals as requested. Inputs to other departments as required e.g. IT, networks, claims. Contribution to projects as entrusted to the department. Generation of periodic reports as expected from the department. United Healthcare India Pvt Ltd. (under UHG), (United Health Group was ranked Fortune No. 1 among health care insurance and managed care companies) Lead Quality Analyst - May ‘10 – June' 12. Underwriting review of all the medical documents pertaining to insureds belonging to different insurers. Providing the medical judgement regarding the insurability of the members based on their health and other risk factors. Conducting medical assessment of proposed insureds through the medical check up’s proposed as per company norms and providing the insurers regarding the result of those tests and insurability status. Managing QA team and maintain 100% accuracy in delivering information to UHC’s clients that are primarily Insurance organizations. Maintain quicker TAT (Turnaround Time), in providing reports to clients and authenticating those reports. Scrutinize Pre Insurance Medical reports before they reach out to client and eliminate queries that may cause delay in approval process. Some of the top clients that I work with are: 1. AEGON Religare 2. Bharti AXA 3. MetLife 4. SBI 5. ICICI Lombard 6. Max New York 7. Canara HSBC 8. DLF Pramerica 9. MAX Bupa 10. ICICI Prudential Manage Pre Employment Check-ups & provide Fitness statuses to the concerned HR departments of the clients. Some of the clients include top class organizations such as: 1. AXIS Bank 2. Fidelity 3. JP Morgan Financiers 4. Writer’s corporation 5. L’Oréal 6. Alcatel Lucent 7. Noetix 8. Facebook 9. Aditya Birla Roles and Responsibilities: As a QA Lead, I interact with several Insurers and Doctors at Diagnostic Centres to validate the information, before approving Medical reports within the TAT. Grievance handling – This is another challenging area that I deal with, for a timely closure of grievances, sustaining the relationships stronger with the clients of UHC. Grievances are tracked through QMS tracker and are usually closed within the stipulated TAT of 24 hrs. I also work with the Grievance cell in the organization to review grievances reported to other departments to ensure similar grievances are prevented within my department. This proactive work helps in minimizing the error rate within my department. Providing orientation to Diagnostic Centres regarding Quality aspects of the reports Training QA team in handling issues, dealing with DCs (clients) Providing TAT reports to senior Management in a timely manner with progress updates Work with other internal team heads such as Network team and empanel good DCs that can provide quality service. I also monitor their service and provide feedback to Network team from time to time, suggesting for reorientation of DCs if necessary, in order to maintain quality service Managing scanned copies of reports that are uploaded to the Company website (“Finedocs”) in a timely manner, so that Insurers can download reports for faster closure. Product Knowledge: to have thorough understanding of the following: Life Konnect business. Basic formats for all life insurance companies. Documentation requirements of insurance companies. Service Orientation: Ability to anticipate customer needs – To understand client growth plans, market conditions and prepare for any requirements that might arise as a result of the same, e.g. network growth in new areas, implementation of new protocols. Achieve Customer Delight by following and constantly enhancing high service standards set by company. Inter and Intra-departmental Coordination: To ensure that all customer deliverables are executed within set timelines by coordinating with various internal departments. To work as part of a team and ensure that the network services, call centre and Life-Konnect operations are kept informed of all developments on the insurer and provider front. Escalation Handling To differentiate between situations that require to be escalated and those that can be solved without involving the HOD To ensure that all genuine escalations are handled quickly and effectively so that no inconvenience is caused to the client / provider To route all escalations through proper channels. Heritage Health TPA Pvt Ltd.    Medical Officer - Claims from July 2009 – April 2010. A dynamic professional with nearly 1 year of experience in Claims Processing, Pre Authorization, Client Relationship Management and Documentation. Exposure in managing claims of various product portfolios including visiting the spot of loss, making thorough physical inspection, scrutinizing supporting papers, books of accounts as per the requirement and submitting independent reports. Consummate professional with excellent planning, execution, monitoring and resource balancing skills, attention to detail as well as the ability to build and lead effective teams. Outstanding presentation and leadership skills. Abilities in cementing healthy relationship with the clients for generating business and leading workforce towards accomplishing business and corporate goals. Possess excellent interpersonal and organizational skills with proven abilities in customer relationship management and planning. I will give medical opinions regarding the different claims we receive. I mainly give Pre Authorizations for claims from                         National Insurance from Hyderabad Branch,                         United Insurance from Chennai Branch,                         New India Assurance claims from Vizag branch.                         Oriental Insurance. I mainly interact with the clients regarding any claims and give the medical opinions regarding the admissibility of the claims whether they are payable or not. I deal with Individual policies from National, United, Oriental, New India Assurance and so many corporate clients like OCV Reinforcements, TATA Projects limited, DST,VST Technologies, Cream line Dairy Products, Rane Engine Valve, AP Tourism(APTDC),AP Mineral Development (APMDC), Flagstone etc. I give authorizations or repudiations for the Reimbursement claims based on their admissibility according to the terms and conditions of the policies. Under National Insurance I used to deal with different policies like                  Individual Mediclaim Policy                  Family Parivar Policy                  Varishta Policy for the elderly people                  Personal Accident Policy                  Universal policy Under United Insurance I used to deal with different Policies like                   United Platinum Policy for the youngsters                   United Gold Policy for the Middle Age People                   United Senior Citizen Policy for the People aged above 60 yrs.                   United Family Policy                   United Individual Medicare Policy. Under New India Assurance I mainly used to deal with                   Individual Policy                   Janatha Policy I am experienced in coding of different Diseases based on the ICD (International Coding for Diseases) for different claims we receive. I give Medical opinions for different claims regarding the amount payable for a particular claim based on the tariff for the different procedures for the different ailments. I will be enthusiastic to know the latest advancements in the Medical field and what are the new techniques and Treatment procedures that will be adopted by different hospitals for different ailments and the cost of the procedures and their indication in which kind of ailments. Hospital Experience: From February 2007- June 2009: Worked in 3 different multi-speciality hospitals to gain medical experience. Education: BHMS (Bachelor of Homoeopathic Medicine and Surgery).  MBA (Healthcare Management) from ISBM through Distance mode. IPGD (LI) from IIRM, an affiliated institute to CII, London. Licentiate and Associate from III (Insurance . Pursuing Diploma from CII (Chartered Insurance Institute, London). Giving P-85 claims practice exam in coming April, 2016. Accolades: Service recognition award from CEO of SATMED in 2013. Star of the month for March 2015 and May 2015 for 0% errors and 100% quality productivity.