Moumita Goswami

Project-Healthcare Insurance Role- Appeal Specialist

• Acted as claims examination subject matter expert for clients. Received formal appeals and/or complaints; investigated the circumstances and research applicable laws, rules, regulations, and policy.
• Reviewed over 50 patient cases per week and verified insurance coverages.
• Track and closely monitor requests for prior authorizations through approval.
• Made recommendations in written and oral form regarding appropriate corrective action to be taken as a result of a review and/or appeals decision.
• Made non-clinical appeal determinations as permitted by department business processes and guidelines.
• Participated in cross-functional teams to implement changes in business operations processes.

PROJECT – Financial Services Role- Data Analyst

• Performed Data Validation.
• Developed and implemented operational strategies to improve efficiency in daily operations.
• Analyzed and removed duplicate information on the client master data management system with accuracy and on a timely manner.
• Provided the branches with direct support by prioritizing and following the procedures and policies defined by the client.
• Performed data management functions on branch records to merge, edit, modify or delete data as required while following the client’s compliance and policies.
• Optimized existing database structures for better performance on analytics tasks.

• Worked on Client's online content management systems
• Flagged inappropriate contents and escalated issues to superiors to resolve them in a timely manner
• Identified key metrics to evaluate data both quantitatively and qualitatively
• Implemented strong analytical and creative skills in reviewing videos.
• Monitored website analytics, providing detailed reports on user engagement levels.
• Provided technical support for software applications used by the team during development process.

• Reviewed, evaluated, and determined the validity of member grievances and appeals.
• Analyzed data from all sources to determine root cause of grievances and develop solutions.
• Received, investigated, and responded to formal appeals and complaints of members and performed related duties as required.
• Resolve the complaint by taking appropriate action or by explaining to the members the reasons for the original decision.
• Examined claims, records and procedures to grant approval of coverage.
• Experienced in handling external parties such as Plan Partners, Primary Care Physician (PCP) offices, pharmacists, etc.
• Conducted Member eligibility Verification, supported member request for ID cards and PCP changes.
• Proficient and knowledgeable of specified applications such as Cisco, NICE, QMEIS and MEIS.