Santhosh Kumar Karigalla
Health Informatics Analyst @Cigna Healthcare
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WORK HISTORY
Health Informatics Analyst @Cigna Healthcare
Bloomfield, CT, US
Perform research and analysis of complex healthcare claims and pharmacy data to identify network utilization patterns and cost containment opportunities, supporting quarterly financial reviews.• Develop and optimize complex SQL queries with CTEs and window functions to extract claims data for methodology validation and ad-hoc analyses requested by internal departments.• Design and distribute standard reports using SQL and Tableau, tracking claims processing accuracy, denial rates, and turnaround times against departmental KPIs.• Identify and investigate anomalies in claims trends, performing root cause analysis on payment discrepancies and recommending corrective action plans to management.• Collaborate with Product and Clinical teams to translate business requirements into technical specifications for system enhancements and new reporting capabilities.• Validate clinical relevance of claims outputs by cross-referencing ICD-10 and CPT codes with medical documentation, ensuring alignment with regulatory guidelines.• Document reporting processes and maintain audit trails for all methodology changes, supporting internal compliance reviews and NCQA accreditation efforts.• Test system enhancements in Facets, identifying 10+ defects prior to deployment and ensuring seamless integration with upstream data sources.Environment: Facets, SQL, Tableau, SSRS, Excel, HIPAA, SharePoint, Commercial Insurance Plans
EDUCATION
Holy Mary Institute of Technology and Science
Bachelor of Pharmacy - BPharm, Pharmacy
Governors State University
Master's degree, MS in Healthcare informatics
ABOUT SANTHOSH KUMAR KARIGALLA
I’m a results-driven healthcare professional with over five years of experience in pharmacy benefits management, quality assurance, and process optimization at Optum Global Solutions. I specialize in auditing pharmacy claims, supporting TPA operations, and driving process improvements that reduce errors and improve compliance. My background in pharmacy, combined with hands-on experience with tools like RxBK1, RxClaim, and macros, has enabled me to lead benefit audit teams with precision and efficiency.As a current student at Governors State University working toward a Master of Science in Health Informatics, I have a strong interest in integrating technology and clinical care. In order to contribute to creative, patient-centered healthcare solutions, I\'m honing my advanced skills in data analytics, EHR systems and regulatory requirements. Known for my analytical mindset, attention to detail, and collaborative spirit, I aim to bring a blend of technical expertise and healthcare knowledge to organizations focused on improving care delivery and operational performance.Let’s connect—I’m open to internship opportunities and collaborations that advance healthcare innovation.
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