Dharani Kumar G
• US Healthcare Payor Operations • Medicare Advantage & CMS Compliance
• Claims Adjudication & Enrollment Lifecycle • Client Engagement
• Business Analysis (BRD, SRS, Project Charter) • Product Development & System Implementation
• EDI (834, 837, 810, 850) & ANSI Error Resolution • Testing Strategy(Functional,Regression,Integration,UAT)
• Automation & OCR Implementation • Client Engagement & Executive Reporting
• SQL, XML & Configuration
Medicare Membership Management – Enrollment, Disenrollment, Reinstatement, PBP Change, 4Rx Chage,
NUNCMO, Premium Billing, PCP/Specialist/Risk Attribution, BEQ, OEV, Marx, TRR, Monthly Maintenance,
Materials, Exhibits, ANOC, LIS, LEP, SNP Verification, Chapter 2, PCUG, Chapter 4, Payment & Member
Reconciliation, CMS maintenance files.
Claims Management – Claims Load, Paper/EDI, OCR, Invalids, Adjudication, Rules/Edits, Fee Master, Denial
Master, Hold Master, Service Category, Dx Master, CPT Master, Code Masters-Value codes, Occurrence
codes, Condition codes, Benefits, EOB, TFL, G & A, Adjustments, Reimbursements, Authorization, High
Dollar, OIG Validation, Sequestration, Interest Payment, Encounter submissions, Delegated vendor claims.
Provider Management – Par/Non-Par, Groups, Rate Upload, Capitation, Provider/Facility Master, Contracts
Configuration, Third Party Transmissions
Accountable Care Organization – Quality Metrics, Dashboard, MLR’s, CCLF, ALR, Risk Scores, HCC
Master/Re-capture, Estimated Benchmark vs. Actual Expenses, Calculating Cost Savings and Shared Savings
based on the ACO Models.
Software/Product Analyst – Requirement Gathering | Project Planning | BRDs | Testing & Sign off | CMS
File Transactions | Project Transition | Product Migration | Product Demo| Third Party Integrations| BDD.
Products/Modules – Medicare Enrollment, Claims All LOB, PDM, OCR, ACO, Reports, Portals.
Business Development – Lead Generation, Tier Categorization, Filtering target audience, Identifying Prospects, Connection & Networking, Social Media Marketing, Sales Pitch, Business Meeting/discussion, Recommending Solution/Service, Conversion, BAA Collaboratives.