Shruti Gangwar
Holly Springs,NC
Summary
Dedicated professional with a proven track record in Benefit Verification, Quality Assurance, and Auditing. Passionate about optimizing patient care through precise insurance assessments, ethical compliance, and empathy. Eager to contribute a unique blend of skills and experiences to drive organizational excellence and growth.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Reimbursement Case Manager
Mercalis
Morrisville, NC
10.2023 - Current
- Audit 30 accounts per day ensuring processes, procedures and cadences are followed correctly per SOP, troubleshooting and resolving any issues that prolongs the patient’s journey.
- Performed benefits investigation, prior authorization, and appeals process to determine patient eligibility and coverage per their plan.
- Worked independently to complete assigned work in accordance with Standard Operating Procedures and defined Service Level Agreement SLA to complete benefits verification process, PA & appeals.
- Strong compliance mindset, with clear understanding of patient privacy laws & HIPPA.
- Made Outbound calls to gather information related to case, insurance coverage, prior authorization (PA) or appeals follow up.
- Expertise to work with medicare, medicaid, DOD, Tricare , VA health and various commercial insurances
Volunteer
Nimpy Ninja
Raleigh, NC
01.2023 - Current
- Specialized in Clinical Data Preprocessing using Salesforce
- Responsible for the extraction, filtering, and seamless transfer of patient's clinical data into Salesforce to support advanced AI and ML analyses
- Identify & remove duplicate records & merge data from multiple source into a single dataset
- Ensuring impeccable data accuracy, strict privacy compliance, and unwavering adherence to quality standards.
Insurance Verification QAQC
IBM
Raleigh, NC
03.2021 - 12.2022
- Conducted independent audits of 200+ agents, meticulously reviewing processes and outbound call activities related to pharmacy and medical claims
- Produced comprehensive quality reports, educated staff to enhance compliance, and promptly escalated non-compliance matters to management
- Applied healthcare expertise to conduct audit procedures, establish criteria, and generate 20± reports daily following SOPs and client expectations
- Maintained full PHI, HIPAA, Jcodes, CPT, and ICD-10 compliance while vigilantly auditing all transactions for insurance accounts
- Proficiently addressed insurance verification issues, encompassing billing audits, copayment accuracy, deductible, and prior authorization
- Trained & mentored new hires. Monitored trainee progress and provided constructive feedback.
- Worked with patients, pharmacy, provider, and payor. Adhere to PHI/HIPAA compliance.
- Verified insurance coverage benefits, including deductible, co-insurance, and out-of-pocket maximums for Specialty drugs.
- Ran Test Claims on RxHome and Pega software.
- Utilized third-party websites (Trizetto, RPA, Availity, CoverMyMed) to verify insurance coverage benefits and initiate authorization requests.
- Obtained Prior Authorization process for specialty drugs based on Jcode.
- Followed up on authorization statuses by contacting payor & prescriber.
- Documented calls in tracking systems RxHome/ Pega and handled escalated tasks per established procedures.
- Worked with Medicare, Medicaid, Tricare, DoD, Commercial insurances, BUY and BILL. Worker's Compensation.
- Consistently met or exceeded Key Performance Indicators (KPI).
- Proficient in utilizing Outlook email, Skype for Business, Cisco Web-Ex, OneNote
Business Development Coordinator
Wordsmith Ideas
Apex, NC
05.2015 - 07.2017
- Conducted Inbound and Outbound client interactions, gathering requirements, and delivering tailored solutions to ensure the highest customer satisfaction.
- Proficiently processed payments, adjustments, denials, and expense tracking in adherence to established guidelines using Excel.
- Streamlined data entry and administrative tasks, including filing, copying, and scanning records.
- Excelled in multitasking, meeting tight deadlines. Showcased strong
- organizational, interpersonal, and communication skills.
- Efficiently coordinated event planning and managed client-vendor relationships per protocols.
Education
Master of Science (M.Sc) - Chemistry
SNGGPG College
Bachelor of Science (B.Sc) - Life Science
SNGGPG College
Bachelor of Education -
All Saint's College
Skills
- Customer Service
- Agile Learning
- Insurance & Benefit Verification
- Process & Call Auditing
- HIPPA & Regulatory Compliance
- Process Facilitation & Training
- Major Medical & PBM, Specialty Pharmacy
- Claim Processing, Prior Authorization & Appeals
- Medicare, Medicaid, Tricare & DoD
- Proficient in Google workspace & MS Office
- Excellent Interpersonal, organizational & analytical skills
- Empathy, Ethical Conduct and Attention to Details
Certification
CompTIA A+ CERTIFIED
Timeline
Reimbursement Case Manager
Mercalis
10.2023 - Current
Volunteer
Nimpy Ninja
01.2023 - Current
Insurance Verification QAQC
IBM
03.2021 - 12.2022
Business Development Coordinator
Wordsmith Ideas
05.2015 - 07.2017
Master of Science (M.Sc) - Chemistry
SNGGPG College
Bachelor of Science (B.Sc) - Life Science
SNGGPG College
Bachelor of Education -
All Saint's College
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