surabhi S.

Process and resolve appeals and correspondence related to denied, delayed, or incorrectly processed healthcare insurance claims while adhering to payer guidelines and turnaround SLAs. Review documentation from members and providers to identify suitable resolution paths and appropriately route appeals to specialist teams for complex adjudications. Facilitate communication and dispute resolutions among healthcare providers, insurance companies, and patients to ensure transparency and accuracy. Manage general and property & casualty insurance processes, including policy administration, underwriting support, policy issuances and renewals, and claims coordination. Conduct Quality Assurance and internal audits for processed claims, identifying discrepancies and implementing corrective actions to maintain first-pass quality standards. Uphold SLA adherence and contribute to process improvement projects that align with client expectations and operational KPIs. Interpret EOBs and apply ICD-10, CPT, and HCPCS codes for accurate coordination of benefits and payment outcomes.

Conduct comprehensive audits of both paper and electronic claim documentation, pinpointing error root causes and sharing findings with team leads for process adjustments. Create and present training sessions and knowledge-sharing workshops for new hires and junior claims specialists, focusing on claims adjudication, payer rules, and HIPAA compliance. Supervise performance metrics such as accuracy, TAT, and AHT, implementing corrective strategies that effectively reduced rework rates in the claims processing team. Investigate and adjudicate daily incoming claims via multiple payer systems and tools, addressing aged accounts and servicing queries received through various channels. Ensure that medical and hospital claims are accurately processed and verified in compliance with payer requirements, making necessary billing adjustments based on EOB reviews. Audit high-cost outlier claims through the entire process from billing to payment/resolution, confirming the accuracy of claims submissions for timely reimbursement. Address escalated claims issues to ensure resolutions align with regulatory and compliance standards, while maintaining detailed escalation logs. Safeguard the confidentiality of Protected Health Information (PHI) in strict compliance with HIPAA guidelines throughout all documentation and communication activities. Manage O2C processes including order management, billing, invoicing, and reconciliation to provide comprehensive support for client operations.