Santosh Adimulam

 Address: 17-219, New venkateshwara Nagar, North Lalaguda, Secunderabad, 500017, Hyderabad, India
 Email address: pallisanthu@gmail.com  Phone number: (+91) 9959580029
Gender: Male Date of birth: 15/08/1990 Nationality: Indian

MANAGEMENT AND
LEADERSHIP SKILLS
Roles and Responsibilities
◦ Handling a large team of 40 plus associates.
◦ Training the new users/associates while onboarding.
◦ Filling the gaps in the process.
◦ Drive accountability with team leads and their teams to meet quality performance
goals and ensure program standards are met on a week over week basis
◦ Assess and prioritize the top-quality issues affecting the teams on your site across
all decision-making channels
◦ Provide details to local teams around the impact of the policy change on the
team's current work and surfaces gaps in knowledge, process, and technology
between the intent of the Content Policy and how content review takes place
◦ Actively re-review decision accuracy audits to ensure consistency and alignment
with our internal policies
◦ Facilitated the execution of worldwide C- Ops QA strategy through local
management, operations teams, and support teams
◦ Responsible for documentation of quality metrics, communicating root causes to
operations, and carrying forward lessons learned from quality concerns
◦ Verified Quality Metrics in place and met goals, triggered containment actions and
corrective actions as appropriate
◦ Managed, coached, and developed a high performing Quality team that meets
agreed objectives, and which delivers best practice results, added value, and
continuous improvements
◦ Communicated across all levels on Operations and program progress. 
◦ Provided focused feedback loops for teams based on performance and quality
data.
◦ Conducted Root Cause Analysis (5 Whys Analysis/ Fish Bone Analysis) and Error
Trend Analysis
◦ Drove defect elimination program by working along with Ops and Program
stakeholders.
◦ Drove efficiency improvements by eliminating nonvalue add processes and
introducing automation capabilities- Analyzed the key levers of the business to
identify trends and proactively take action to improve efficiency and quality.
◦ Worked with software teams to articulate and prioritize feature needs for systems
and tools.

DIGITAL SKILLS

Core Competencies
FMEA | Quality Management | SOP validations and recommendation | Transition
Management | Rigorous and Prag | Operations monitoring | Quality Management
System | Stake holder management | Continuous Quality Improvements | Change
management | Quality Green Belt Projects | Corrective actions | User Acceptance
Testing | Team building | Multitasking abilities | Process Excellence | Internal and
external auditing & reporting | Leadership training | Analytical skills | Training
solutions development | Process evaluation and enhancement | Process validation |
Defective analysis

Digital Skills
COMET | UNet | Availity | Blue Square | 7 QC tools | Reflection space
 WORK EXPERIENCE

[ 14/09/2020 – Current ] Quality Control Analyst

Legato Health Technologies

City: Hyderabad
Country: India
Main activities and responsibilities:
◦ Handled a large team of 40+.
◦ Identify and obtain additional information needed to make an appropriate
determination
◦ Leverage appropriate resources to obtain all information relevant to the claim
◦ Obtain relevant medical records to submit appeals or grievances for additional
review, as needed
◦ Analyze/research/understand how a claim was processed and why it was denied
◦ Audit assignment on a daily basis to other QA. 
◦ Publishing the Audit reports & Error Trends.
◦ Conducting Team Huddles for variances on a Daily, Weekly, and Monthly basis.
◦ Leading the Calibration process between the Operations and Quality Team.
◦ Conducting GEMBA session.
◦ Leading the Calibration process between the Trainers and Quality Team.
◦ Conducting PKT on a Monthly basis.
◦ Weekly Calibration with OE.
◦ Training and mentoring the new QAs in the Team.
◦ Providing Floor support to the Operations.

[ 04/11/2019 – 13/09/2020 ] Associate

WIPRO LIMITED
City: Hyderabad
Country: India
Main activities and responsibilities:

◦ Claims failed at the auto adjudication level require processing, which involves
interpretation of claim forms, timely submitted filing proofs, eligibility related
forms, receipt of payments given for a particular service, employer’s records, and
provider’s or customer’s reports and statements along with other supportive
documents attached to perform the necessary action.

[ 24/09/2018 – 03/10/2019 ] Senior Analyst

R1 RCM Global Private Ltd

City: Hyderabad
Country: India
Main activities and responsibilities:
◦ Complete knowledge of US Health Care, concepts like Patient responsibilities (Co-
Payment, Deductible, and Co-Insurance & Premium), Explanation of Benefits
(EOB), Out of pocket (OOP), Timely Filing Limit, Payment methods, Coordination of
Benefits & Carve-Outs.
◦ Researching and analyzing the Health claims HCFA 1500 & UB04 forms.
◦ Enrolling the new members into the network.
◦ Checking the eligibility status of Medicare and Medicaid claims, payment postings,
& Bankruptcy claims.
◦ Adjusting the EOB & COB billing information in the claims
[ 27/07/2015 – 14/09/2018 ] Claims Associate

Optum Global Solutions

City: Hyderabad
Country: India
Main activities and responsibilities:

◦ Determine whether an additional appeal or grievance reviews are required (e.g.,

medical necessity) and whether additional appeal rights are applicable
◦ Determine where specific appeals or grievances should be reviewed/handled, and
route them to other departments as appropriate
◦ Identify and obtain additional information needed to make an appropriate
determination
◦ Document final determination of appeals or grievances using appropriate
templates, communication processes, etc. (e.g., response letters, Customer Service
documentation)
◦ Communicate appeal or grievance information to appellants (e.g., members,
providers) within the required timeframe (e.g., DOL, DOI)
◦ Recognize issues related to variable deductible, coordination of benefits; carve-out
alternate benefits.
◦ Review highly complex benefits for tops compatibility
◦ Analyze the claim forms in order to determine their accuracy and completeness,
and analyze the benefits offered to a policy to determine if the treatment is
covered and the extent of the liability of the insured and insurer.

EDUCATION AND
TRAINING

[ 07/05/2010 – 06/07/2013 ] B.Com (Computers)

Kakatiya Degree College

Address: Hyderabad

[ 09/06/2008 – 07/04/2010 ] Intermediate

Gowtham Junior College

[ 05/06/2004 – 02/03/2008 ] SSC

Shanthinikethan High School

LANGUAGE SKILLS

Mother tongue(s): Telugu

Other language(s):
English
LISTENING C1 READING C1 WRITING C1
SPOKEN PRODUCTION C1 SPOKEN INTERACTION C1