SIVAKUMAR REDDY
Dubai
Summary
Highly Motivated Healthcare Professional looking a Challenging
position in a professional organization wherein I can contribute
to the successful growth of the organization by Utilizing the
Technical skill, knowledge and experience.
Currently working as PBM-Claims Officer since 3 years in
NAS-Neuron Health services
Overview
9
9
years of professional experience
1
1
Certification
Work History
PBM-Claims Officer
NAS Neuron Health Services LLC
07.2021 - Current
- To Monitor the PBM approvals.
- To issue online and verbal authorizations based upon member coverage & medical justification.
- Able to accurately assess eligibility within the UAE (HAAD and DHA/MOH ) guidelines as well as policy boundaries.
- High cost Medication adjudication including biologicals and chemotherapy.
- To Resolve PBM denial/Rejection queries from providers and payers via phone calls or e-mail
- Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame
- Ensure adherence to the predefined TATs for Pharmacy claims and Pre-approvals
- Reviewing insurance policy provisions, coverage limits, and exclusions to determine if coverage exists for specific claims
- Conducting investigations to determine the validity of claims
- Reviewing insurance claims, identifying errors, and making recommendations for changes
- Ensures the proper communication and implementation of new formats, training, and processing rules.
Senior Pharmacist & Insurance Coordinator
ASTER DM HEALTH CARE
02.2016 - 06.2021
- Supervised and coached team of pharmacy technicians and trainees
- Provided consultations and answered inquiries from patients, healthcare professionals and physicians regarding drugs, potential side effects, and specified use
- Process prescriptions through e-claim for insurance management
- Analyzing documentation to determine whether claims are valid based on industry standards and regulations
- Reviewing insurance claims, identifying errors, and making recommendations for changes
- Preparing, Reviewing and Transmitting claims for processing with Coding Medical Records with accurate ICD 10 CM codes
- Achieved and maintained top customer satisfaction and retention by cultivating productive relationships with patients
- Counseled patients on proper use of medication and potential drug interactions
- Purchased and organized supplies while maintaining compliance with proper storage procedures.
Education
Master of Science - Pharm-D
Jawaharlal Nehru Technological University
Andhra Pradesh10.2015
Skills
- Fluency in MS Office
- PBM
- Time Management
- Customer Service
- Flexible and Adaptable
- Organizational Skills
Certification
- Ministry of Health & Prevention Pharmacist License
- Adhara Pradesh Pharmacist License
Languages
English
Advanced (C1)
Telugu
Bilingual or Proficient (C2)
Hindi
Intermediate (B1)
Malayalam
Elementary (A2)
Timeline
PBM-Claims Officer
NAS Neuron Health Services LLC
07.2021 - Current
Senior Pharmacist & Insurance Coordinator
ASTER DM HEALTH CARE
02.2016 - 06.2021
Master of Science - Pharm-D
Jawaharlal Nehru Technological University
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