Frankleen Francis

Dedicated and detail-oriented Claims Adjudication Specialist with 6 years of experience in analyzing, processing, and adjudicating medical insurance claims. Proficient in evaluating claim submissions for accuracy, compliance with policy guidelines, and medical necessity. Strong understanding of medical coding (ICD, CPT, HCPCS), insurance regulations, and healthcare reimbursement methodologies. Skilled in resolving claim discrepancies, handling appeals, and ensuring timely claim settlement. Adept at working with health insurance policies, provider contracts, and regulatory requirements (HIPAA, CMS guidelines, and payer-specific policies) and internal teams. Experienced in utilizing claims processing systems and collaborating with cross functional teams to optimize claim adjudication workflows. Strong understanding of industry guidelines, insurance protocols, and claim adjudication systems. Strong problem-solving and analytical skills with a focus on reducing claim denials, enhancing accuracy, and improving customer satisfaction. Knowledge of UAE healthcare and insurance policies, with a track record of reducing claim errors and improving adjudication efficiency. Seeking a challenging role in a reputed insurance or healthcare company in the UAE.

Medical Claims Specialist (Nttdata business solutions)

Key Responsibilities:

*Claims Processing Adjudication : Process and adjudicate medical claims efficiently for accuracy, completeness, and compliance with policy terms.

*Policy & Compliance Analysis: Assess claims against policy guidelines, state regulations, and insurance laws to determine eligibility and payment.

*Data Verification: Investigate claims by reviewing medical records, diagnostic codes, and treatment histories to verify eligibility, benefits, and medical necessity. 

*Decision Making: Approve, deny, or escalate claims based on supporting documents and medical necessity. 

*System & Reporting: Utilize claims processing software to document cases, update claim statuses, and generate reports for management review.

*Customer Support: Assist policyholders and providers with claim-related inquiries, explaining coverage limits, reimbursement policies, and denial reasons. Identify and prevent fraudulent or duplicate claims through thorough investigations. Liaised with internal and external stakeholders, ensuring smooth claims settlement. Work closely with healthcare providers, hospitals, and insurance companies for claim approvals and dispute resolution. 

*Process Improvement: Identify inefficiencies in the adjudication process and recommend improvements to reduce turnaround time and errors. End-to-end claims adjudication for various health insurance plans, reducing claim processing errors by [80]%. 

*Training and Technical Support :Provided training and guidance to junior claims adjudicators on policy updates and claim adjudication best practices. Knowledged in UAE healthcare and insurance policies, with a track record of reducing claim errors and improving adjudication efficiency

I have completed Bachelor of Computer Application degree at Bharathiyar University,India.