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About

Healthcare claims testing and validation professional with 10+ years in US health insurance (payer) operations across Evolent Health, Infosys BPM, Syntel, and TriZetto. Hands-on experience creating and executing functional and end-to-end claims test scenarios, validating adjudication, benefits, pricing, and payment outcomes, and logging and tracking defects through resolution. Skilled in SQL data validation, root-cause analysis of configuration issues, and gathering requirements from business stakeholders to build test coverage. Working knowledge of HealthRules Payer (HRP) claims processing, EDI 837 file validation, Blue Card claims, and HRP-to-TPA workflows, along with FACETS and QNXT payer platforms; strong communicator with business and technical teams. Recipient of 4 consecutive Spot Recognition Awards (2022–2025).

Experience4

  1. Senior Analyst – Claims Payment Integrity, Funding & Recovery

    Sep 2021 — Jan 2026

    Evolent Health International Pvt. Ltd.

    Built UAT and QA validation plans and test scenarios for system changes and new implementations across 6 payer clients, ensuring process and data integrity. Validated end-to-end claims payment workflows including member terminations, overpayments, refund postings, and recoupments. Used SQL queries to validate high-volume claims data, reducing manual data-prep time by ~30%. Managed defects in Jira, Pareo, and MPX through resolution. Created Power BI dashboards automating reconciliation reporting, reducing turnaround time from days to minutes. Earned 4 consecutive Spot Recognition Awards (2022–2025).

  2. Process Specialist – Aetna Project (Medicare Appeals)

    Jul 2018 — Aug 2021

    Infosys BPM Ltd.

    Audited and processed pre-service and post-service Medicare appeals following CMS guidelines in a high-volume environment. Served as Subject Matter Expert for appeals and claims-processing queries; mentored junior staff and led new hire training. Generated performance reports and streamlined workflows using claims platforms, improving throughput and reducing errors. Awarded Best Performer for consistent quality and productivity.

  3. Associate – KPO Healthcare (Humana)

    Aug 2016 — Jun 2018

    Syntel India Ltd.

    Performed claims analysis, bug testing, and automation testing supporting Humana healthcare QA cycles. Prepared QA reports and test scenarios; identified and resolved critical data integrity issues pre-production. Managed MOOP adjustment projects ensuring regulatory compliance. Achieved 20% productivity gain in Q4 2017 and received the Adaptive Award for process innovation.

  4. Associate – Claims Processing & Validation (Colorado Access)

    Apr 2014 — Jul 2016

    TriZetto India Pvt. Ltd.

    Performed end-to-end claims processing and validation for Colorado Access using FACETS, ICES, and other platforms. Validated pricing and payment accuracy for inpatient and outpatient claims using QNXT and Microdyne Pricer. Identified, documented, and resolved claim discrepancies and denials to ensure timely adjudication.

Education1

  • Bachelor of Computer Applications

    Maharashtra College of Science & Commerce, Pune