Bala Gopal Varma K

About Bala Gopal Varma K

Healthcare IT Manager with 15+ years of deep hands-on experience in EDI, medical and pharmacy claims adjudication, and encounter data, helping health plans and NEMT organizations turn complex regulatory and operational requirements into stable, scalable, and audit‑ready solutions. Experience spans Medicaid, Medicare, Commercial, and international lines of business, with a strong focus on data quality, compliance, and measurable business impact.Specialized in building and leading high‑performing teams that own the full lifecycle of claims and encounters—intake, validation, transformation, submission, reconciliation, and reporting—for both medical (837/835) and pharmacy (NCPDP, PDE) domains. Roles as Business Test Lead, EDI Business Lead, Principal Consultant, and Senior Test Analyst have delivered mission‑critical initiatives for CareSource, Modivcare, BCBSNC, BCBSNJ, Aetna International, and Xerox Healthcare.Core strengths include:• Encounter processing for Medicaid and other government programs (CMS and state‑specific rules, SLAs, error reduction, audit support).• HIPAA EDI transactions including 837 (claims), 835 (remits), 834, 820, 270/271, 276/277, 278, 277CA, plus NCPDP pharmacy claims and Medicare Part D PDE file validations.• Claims, membership, benefits, provider, NEMT, and pharmacy workflows using platforms such as FACETS, NASCO, Modivcare Logisticad, and BCBS custom ecosystems.• Data and ETL testing (Informatica, DataStage, SQL, RedPoint, PowerBI) to ensure >99% accuracy in submissions and analytics.• UAT/EUAT leadership, risk‑based testing, defect management, and onshore–offshore team management with strong stakeholder communication.Recent focus areas:• Leading EUAT for CareSource, validating Medicaid encounter processing against CMS/state mandates and driving data profiling, SLA compliance, and regulatory reporting.• Serving as EDI Business Lead for Modivcare, optimizing NEMT and medical/pharmacy EDI (including NCPDP and PDE feeds) and integrating data tightly with billing and operational workflows.

Experience

1. Manager

   Capgemini

   May 2023 — Present

   Provide technical support during and after the implementation of electronic data interchange (EDI) applications. Troubleshoot problems related to EDI processes and deploy effective solutions. Conduct root cause analysis to prevent future issues and recommend improvements.• Analyze healthcare data to drive process improvement and cost reduction by gathering data from diverse sources and building models to uncover trends, patterns, and insights.• Apply data analysis techniques to healthcare data to create better test suites, ensuring the quality and accuracy. Used tools such as SQL and Excel to extract, transform, and analyze data from various sources, such as electronic health records, claims, and billing.• Manage configuration updates, including benefit plans, provider contracts, claims processing rules, and member eligibility.• Develop and implement test strategies, plans, cases, and scripts for various types of testing, such as functional, integration, regression and user acceptance testing. Translate raw data into meaningful insights for non-technical audiences and evaluate improvements.• Coordinate and collaborate with developers, business analysts, stakeholders, and end-users throughout the software development life cycle, from requirement analysis to deployment and support.• Provide test metrics, reports, and dashboards to measure and monitor test progress, quality, and risks.• Mentor, coach, and train junior engineers, as well as conducting performance reviews and appraisals.• Generate reports and dashboards to visualize and communicate data findings and recommendations to stakeholders.

Education

• Jawaharlal Nehru Technological University

  Engineer’s Degree, Electronics and Communications Engineering

  2006 — 2010