• Demonstrated hands-on experience with the SFDC web application for Case assignment, analyzing benefit requests according to the Client Requirement Document (CRD), and processing them accurately.• Gained practical experience in creating bars, processing claims, and testing claims within the RxClaim application.• Worked on existing plan codes in line with the client's requirements for Cost Saver, WM-Bundle, MyPBM, Drug Coverage, and Accumulation projects.• Ensured timely communication of any issues and provided necessary information to complete case requests.• Developed and managed client-specific implementation plans and processes according to departmental guidelines.• Utilized hands-on experience in running pre-query, plan query, post-query from the Sequel web application system to gather necessary information for implementing plan requests.• Conducted claim testing to ensure accurate claim adjudication.• Engaged in client interactions during weekly huddles for training and issue resolution• Collaborated with multiple teams to complete the Benefit coding with Accuracy & Quality.

Aetna/CVS Healthcare Plan Set Up (PSU)Aetna Middle Market PCC (Plan Coordination Consultant)Code Plan sponsor information, Medical benefits, and Vision benefits into the Policy entry reporting system (PE/RS)Assist with creating account structureIdentify solid Benefit Identification code (BIC)-Sequences and Network IDsProvisions and Line values that appear in Web Customer Inquiry (CCI) as well as feed to Automated Claim Adjudication System (ACAS)Apply federal and/or state legislationUpload additional case file documentation into, Large Group Intake Tool (LGIT) and FileNetParticipate in benefit review

Aetna/CVS healthcare Complaints, Grievances and Appeals (CGA)This role involves extensive healthcare/medical documents analysis ,analytically strong in interpreting the healthcare verbiages.Good knowledge on US Healthcare payer domain. Having knowledge in Complaints, Grievances and appeals experience.Subject expert in US healthcare payer claim adjudication process.Worked on Provider/Member appeals domain.Quality check experience in US healthcare payer domain.

Perform outbound calls to insurance companies to collection outstanding AR.Working on Denials, Rejection, Request for additional information.Strong RCM knowledge & possess good knowledge of HIPPA, CPT codes, Appeals & denial management.

Immense expertise in supplying & trading of Auto electrical spare parts - two wheeler, head lamp relays, meter bulbs etc.