Jyoti John

About Jyoti John

I work as a specialist @Metlife, reviewing and resolving short term disability insurance…

Experience

1. Appeals Representative

   Optum

   Jan 2022 — Present · Noida, IN

   Part of elite Investigation & Solution Group team (I & SG) which reviews written dispute requests received from providers (hospitals & physicians) of denied or incorrect insurance settlement claims based on contractual arrangements with providers and non-contractual providers. • Interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. • Including Medicare guidelines/policies as it applies to contracted and non-contracted providers. • Adjust claims, as appropriate, including calculation of interest and penalties due when applicable. • Identifies potential issues related to fraud, waste and abuse, benefits, eligibility, authorizations, etc.• Affecting the Claims Department’s ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.• Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department.• Responsible for keeping Team Leads aware of potential problem issues for our education to all departments involved with claim issues.• Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.

Education

• Jesus and Mary College (JMC), Delhi

  Bachelor of Elementary Education

  2012 — 2016