AMRATH KIRAN

Handled Medical and Hospital claims processing, claim investigations, resolutions, and adjustments. ✓ Claims Intake – Claims are received from providers via EDI (837). ✓ Eligibility Check – The system verifies if the member is active and eligible for coverage. ✓ Benefit Validation – It checks benefits and coverage rules. ✓ Pricing & Contract Validation – Applies provider contract rates and pricing rules. ✓ Payment & Denials – Determines the amount to be paid or denied based on policies. ✓ Finalization – The claim is finalized and sent for payment processing (EDI 835). • Handled code editing, Void/Corrected/Replacement claims, coordination of benefits (COB), and Examiner manual pricing as per MAC. • Verification or auditing the documents to avoid duplicate and wrong payments. • Clearing blocked invoices and aging invoices with taking necessary actions & Doing RCA to permanent resolution for the issue.

Over 2 years and 8 months of expertise in the U.S. healthcare industry, primarily working with Cigna Healthcare and specializing in Cigna Facets for first-touch claims, adjustments, correspondence, and appeals. ➢ Served as an SME in U.S. healthcare member and provider appeals, specializing in medical and hospital claims, adjustments, and reconsiderations. ➢ Led teams in Cigna Facets appeals, ensuring compliance with standard operating procedures (SOPs) while maintaining high accuracy and quality in claims and Appeals processing. ➢ Conducted comprehensive case investigations to ensure regulatory compliance and collaborated with clients through weekly Webex calls to analyze error trends, implement corrective actions, and discuss process updates, including article revisions and client-side changes. ➢ Drove production efficiency and process improvements, ensuring all performance metrics and SLAs were consistently met.