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Click here or scroll down to respond to this candidateHartford CT EMAIL AVAILABLE PHONE NUMBER AVAILABLE LINKEDIN LINK AVAILABLEEDUCATIONMaster of Health Informatics Sacred Heart UniversityMaster of Hospital Administration Alagappa UniversityBachelor&#Street Address ;s in Physical TherapySree Ratna College of Physiotherapy PROFESSIONAL SUMMARYGraduated - 2023Graduated - 2014Graduated - 2012Results-driven healthcare professional with over 6 years of experience in clinical data analysis, payment integrity management, and claims adjudication within the healthcare industry. Adept at leveraging clinical expertise and advanced analytical tools like SQL, Tableau, and Power BI to optimize patient outcomes, ensure compliance with healthcare regulations such as HIPAA, HITECH, PPACA, and GDPR, and drive strategic decision-making.Proven track record in managing complex and high-value claims, with in-depth knowledge of EHR/EMR systems, EDI transactions, and various clinical case investigation platforms. Extensive experience in utilizing tools like DETECTS, EDSS, and IDRS for accurate data validation, claims processing, and clinical appeals, ensuring adherence to industry standards and reducing processing errors.Skilled in facilitating Agile project management through JIRA and Scrum ceremonies, including sprint planning, backlog refinement, and retrospectives, to enhance collaboration, streamline workflows, and deliver high-quality outcomes within tight deadlines.Strong analytical and problem-solving abilities with a focus on identifying discrepancies between medical records and billed services, managing risk, and implementing data-driven solutions to improve operational efficiency and financial integrity within the healthcare domain.Excellent written and verbal communication skills, with a proven ability to effectively collaborate with cross-functional teams, manage stakeholder relationships, and present data insights that inform business decisions and support continuous improvement efforts.SKILLSFunctional KnowledgeHealthcare Payment and Claim Management, Health Insurance Risk Assessment, CPT/Diagnostic Codes.Productivity and Visualization ToolsMicrosoft Office Suite, Tableau, Power Bi, SQLBasic SkillsProblem Solving, Data Importing, Data Cleaning, Data Transformation, Data Analysis, Data Modelling, Data Visualization, Presentation and Communication Team Management, Technical writing/Documentation, Ticket Management.Healthcare ExpertiseMedicare, Medicaid, EDI, ICD10, HL7, CPT, CHIP, FHIR, EMR, EHR, ICH, FDA, PPACA, HITECH, HlPAA, GDPR, SNOMED, HEDISProject Management Tools and skillsJira, ProjectManager.com, Leadership, Communication, Time Management, Risk Management, Budget Management, Problem-Solving, Task Management, Negotiation, Scrum Ceremonies, Critical Thinking, Stakeholder Management.EXPERIENCEClient: United Healthcare Group (Hyderabad, India)Project: Medicare and Medicaid & Employer and IndividualEmployment Type: Full Time (July 2019 - August 2022 & October 2015 - May 2017)Role: Sr. Recovery/Resolutions Analyst/ Sr. EHR/EMR Business Data Analyst/ Sr. Clinical Investigator/ Sr. Appeals ReviewerUtilized DETECTS and PICTS to streamline electronic claim tracking systems, ensuring accurate adjudication, compliance with HIPAA and PPACA standards, and reducing processing errors in both Medicare and Medicaid claims. Additionally, collaborated with providers to identify and address Fraud, Waste, Abuse, and Error (FWAE) issues, contributing to the overall integrity of the claims process.Employed SQL and Power BI to analyze billing and payment patterns, identifying potential FWAE and Payment Integrity issues. Worked closely with the PNI team and providers to develop and implement corrective actions, ensuring compliance with healthcare regulations and enhancing the accuracy and efficiency of claim processing.Leveraged EDSS and EHR/EMR data to accurately compare patient information such as names, dates of service, provider details, and charges, enhancing data accuracy and supporting informed decision-making across employer and individual claims.Accessed and reviewed EHR/EMR medical records using IDRS and ECAA to validate patient information and verify claims, ensuring adherence to HITECH and GDPR regulations, and mitigating risks in clinical appeals.Processed and analyzed medical records using FASTRIEVE (PDF) and PEGA (Word), employing SQL queries to extract and manipulate data, supporting accurate assessments and decision-making in complex claims.Monitored and validated payment histories through CPW, integrating SQL-based reports to ensure accurate billing and reimbursement processes, contributing to the financial integrity of Medicare and Medicaid programs.Verified CPT and HCPCS coding accuracy using ENCODER PRO and integrated Power BI dashboards to prevent unbundling errors, ensuring compliance with coding standards and optimizing claim accuracy.Conducted in-depth research on CPT, HCPCS, ICD codes, and reimbursement policies using KL and SQL, enhancing clinical decisions, appeals, and strategic data-driven initiatives.Managed allegations and fraud investigations using TIPS, leveraging EDI transaction data and SQL queries to maintain the integrity of the claims process and mitigate risks associated with improper billing practices.Verified patient policies and benefits through iBAAG, integrating SQL databases to ensure appropriate coverage and policy adherence, maintaining compliance with PPACA and HIPAA in the claim adjudication process.Employed ISET and SQL for integrated service tracking, facilitating seamless management of EDI transactions and supporting efficient data processing in the claim's workflow.Utilized CITRIX for secure remote access to applications, data, and EHR/EMR systems, maintaining productivity and ensuring compliance with HITECH and GDPR while working remotely.Streamlined document management processes using SharePoint, integrating Power BI to create interactive reports that enhance collaboration, efficiency, and transparency across teams.Ensured payment integrity using PICTS, analyzing claims through SQL queries, identifying discrepancies, and implementing corrective actions using data-driven insights from Tableau and Power BI.Managed IT service requests and workflows using ServiceNow, enhancing operational efficiency and service delivery within the organization by leveraging data analysis from SQL and Power BI.Performed advanced data analysis on claims and clinical data using SQL, Tableau, and Power BI, identifying trends, assessing risks, and providing actionable insights for process improvement and strategic decision-making.Collaborated with cross-functional teams to reduce claim denials and enhance recovery processes, supported by data visualization tools like Tableau and Power BI, particularly in Medicare and Medicaid services.Led initiatives to optimize claim processing workflows using SQL data queries, identifying inefficiencies and recommending solutions to reduce turnaround times and ensure compliance with healthcare regulations.Developed and maintained detailed documentation of claim processing procedures, ensuring consistency and adherence to industry best practices, as well as compliance with HIPAA, HITECH, and PPACA standards.Provided training and support to team members on the use of applications like DETECTS, EDSS, IDRS, and SQL,fostering a collaborative and knowledgeable work environment.Conducted business analysis using SQL and Power BI, gathering requirements, analyzing data, and developing reports to support strategic decision-making, operational improvements, and compliance with healthcare regulations.Participated in project management activities, including defining project scopes, tracking progress, and ensuring successful delivery of initiatives related to claims processing, system enhancements, and data analysis.Utilized Tableau and Power BI for data visualization, creating clear and concise reports and dashboards that enabled stakeholders to make informed decisions based on real-time data insights.Facilitated communication between business units and IT teams, ensuring that system updates, EDI transaction processing, and enhancements aligned with business needs and complied with HIPAA and GDPR standards.Managed stakeholder relationships by providing regular updates on project status, resolving issues, and ensuring that expectations were met or exceeded through data-driven insights.Utilized JIRA to manage and track progress on various projects, ensuring that all tasks related to claim processing, data analysis, and system enhancements were completed on time and met quality standards.Actively participated in Scrum ceremonies such as daily stand-ups, sprint planning, sprint reviews, and retrospectives to collaborate with cross-functional teams, prioritize tasks, and ensure alignment with project goals and timelines.Facilitated backlog refinement sessions using JIRA to prioritize tasks and user stories related to claims processing and data analysis, ensuring a clear and organized workflow for the development team.Worked closely with the Scrum Master and Product Owner to ensure that the team adhered to Agile principles, usingJIRA to monitor progress and adjust priorities as needed to meet stakeholder expectations.Documented and tracked user stories and technical tasks in JIRA, ensuring that all requirements for data analysis, claims adjudication, and system improvements were clearly defined, met, and validated.Contributed to sprint retrospectives by analyzing JIRA data and generating reports in Power BI to assess team performance, identify areas for improvement, and implement actionable strategies for future sprints.Collaborated with the development team during sprint reviews to demonstrate completed work related to EHR/EMR system enhancements, claims processing optimizations, and data visualization projects, using Tableau and Power BI to present results.Leveraged insights from JIRA and Scrum ceremonies to refine workflows, optimize processes, and enhance the overall efficiency of claims processing and data management operations.Utilized Excel for advanced data analysis and reporting, creating detailed reports and dashboards that provided actionable insights.Leveraged PowerPoint to present findings to stakeholders, ensuring clear communication of complex data and supporting decision-making processes.Developed and maintained comprehensive documentation of data analysis procedures and project workflows usingWord, ensuring consistency and clarity across teams.Used Microsoft Office tools to streamline processes, enhance collaboration, and drive operational efficiency.PROJECTSOptimizing Liver Transplantation Outcomes Through Al-Driven Patient Selection and CareDeveloped an AI-driven model for patient selection in liver transplantation, analyzing vast datasets to identify candidates with the highest probability of successful outcomes, thereby improving overall transplant success rates.Implemented predictive analytics to assess patient health metrics and prioritize transplant candidates, leading to more accurate and data-driven decision-making in liver transplant procedures.Integrated AI algorithms with Electronic Health Records (EHR) systems to streamline the patient selection process, ensuring real-time updates and continuous monitoring of candidate suitability based on evolving health data.Collaborated with multidisciplinary teams to refine the AI model, incorporating clinical expertise and feedback to enhance the accuracy and reliability of patient selection criteria and postoperative care protocols.Achieved significant improvements in post-transplant care by utilizing AI to personalize patient follow-up schedules, predict potential complications, and adjust treatment plans, leading to better patient outcomes and reduced readmission rates.Utilized machine learning techniques to continuously improve the AI model, enabling adaptive learning from newpatient data and outcomes to refine selection criteria and enhance predictive accuracy over time.Conducted comprehensive validation and testing of the AI system to ensure its effectiveness and reliability in real-world settings, collaborating with healthcare professionals to validate results and integrate user feedback for system optimization.Implementing Electronic Health Record (EHR) Optimization - EPICLed a multidisciplinary team in analyzing and optimizing the EPIC EHR system, resulting in a 25% increase in efficiency through strategic planning and execution.Leveraged advanced analytics tools, including SQL, to drive system optimizations, monitor key performance indicators, and collaborate with stakeholders. Implemented iterative improvements to ensure continuous enhancement and adherence to data security standards.Assessed documentation workflows, identified bottlenecks, and implemented solutions to seamlessly integrate clinical data, enhancing overall operational efficiency.Developed and executed training programs for healthcare staff on optimized EPIC EHR functionalities, ensuring smooth adoption of new processes and improving overall user proficiency and satisfaction.Monitored and analyzed user feedback and system performance metrics post-implementation to identify areas for further improvement, leveraging insights to make data-driven adjustments and ensure sustained efficiency gains.Clinical decision support system in Health InformaticsDeveloped and implemented a Clinical Decision Support System (CDSS) to enhance decision-making processes in healthcare, integrating evidence-based guidelines and patient data for improved diagnosis and treatment outcomes.Utilized advanced data analytics tools, including SQL and Tableau, to analyze patient data and generate real-time insights, supporting clinicians in making accurate and timely decisions within the health informatics framework.Ensured compliance with healthcare regulations such as HIPAA and HITECH, while designing the CDSS, focusing on data security, patient privacy, and seamless integration with existing Electronic Health Record (EHR) systems.Created interactive dashboards and reports using Tableau to visualize CDSS outputs and clinical data, facilitating easier interpretation of complex information and enhancing decision support for healthcare providers.Conducted regular evaluations and updates of the CDSS based on user feedback and emerging clinical guidelines, ensuring the system remained up-to-date, relevant, and aligned with best practices in healthcare informatics.A Comprehensive Study on Depression Screening and Factors influencing it in General PopulationConducted a comprehensive survey among U.S. young adults using Google Forms, measuring and assessing their psychological status with the DASS-21 scale while ensuring compliance with regulations related to mental health, substance abuse (SAMHSA), and PTSD.Strategically analyze psychological data utilizing Excel, Tableau, and SQL to drive data-informed insights.Designed and implemented dynamic data visualization dashboards in Tableau, enabling quicker decision-making and generating impactful insight.Identified key factors influencing depression in the general population through advanced statistical analysis and correlation studies, providing actionable insights into contributing variables and risk factors.Developed and presented comprehensive reports summarizing survey findings and trends, tailored for stakeholders and mental health professionals to inform public health strategies and intervention programs.Ensured data quality and integrity throughout the research process by implementing rigorous data validation procedures and maintaining compliance with ethical standards and regulatory guidelines for mental health research. |
