SUBHASH KUMAR

Healthcare Domain Benefit Specialist – United States (US)

` Mobile: +91 7838879279 E-Mail: subhashlaal@gmail.com

Profile Summary

• A competent US Health & Welfare Benefit specialist with nearly 10 years of experience in US Health & Welfare Benefits across
Service Providing Industry
• Instrumental in providing consulting and strategic direction on health & welfare US benefit issues including COBRA, Health Saving
Account, Flexible Spending Account, medical, dental, vision, claims, retiree and so on
• Providing claims/appeals audit, training to the team associates/colleagues, performing activities for new implementation
• Collaborate with clients, stakeholders and other internal parties to ensure timely delivery within agreed quality standards and
provide timely solutions
• Research, Process and take determination (decision) on claims & appeals (Level 1 and Level 2), using number of resources, such as
Total Benefit Administration, Citrix, Lotus Notes, Mainframe, NICE, HRO Maestro & Control D, client plan documents/SPDs, and
client guidelines, for a designated group of clients within ERISA rules
• Direct interaction with end clients and stakeholders for US Health and Welfare Level 2 Appeal process (Presenting the Level 2
Appeal to the committee over the call)
• Assume project responsibility for specific activities or processes within the Claims and Appeals Management (CAM), such as
training and reporting
• Review the claims/appeals research and determination letters for the associates/colleagues before mailing to the employees
• Keen customer centric approach with skills in addressing client priorities and resolving escalations; developing effective day-
today working relationships with the client, third party vendors and stakeholders and other internal parties to ensure seamless
delivery on specific tasks, special projects and/or participant issues

Core Competencies

Health & Welfare Benefits Service Delivery & SOPs Client/ Stakeholder Engagements

Process Re-engineering Reporting & Documentation

Notable Accomplishments

For Wipro Limited

Received appreciation for
• creating the determination letter templates,
• client email templates,
• providing client specific training for the various clients
• Level 2 Appeal process templates

I work in Claims and Appeals Management (CAM) process in Wipro. CAM reviews claims, and appeals received from the employees for
the various clients, concerning enrolment and eligibility issues for Plans covered under the Employee Retirement Income Security Act
of 1974 (ERISA) (US Healthcare Benefits). After reviewing the claims and appeals by researching all the details going through the
multiple applications, CAM takes the determination in accordance with the US Healthcare Plan Provisions and sends the determination
(denial/approval/compliant, non-compliant letters) letter to the employees. CAM also provides the Level 2 Appeal Packets to end clients
and presents the Level 2 Appeal to the Appeal Committee Members over the call.
Work Experience

Since February 2018 through current date: Wipro Limited as Solutions Delivery Analyst (SME/Client Delivery)
in Health & Welfare Domain

Key Result Areas:

• Direct interaction with end clients and stakeholders for US Health and Welfare Level 2 Appeal process (Presenting the Level 2
Appeal to the committee over the call).
• Handling the escalations receive directly from the end clients & stakeholders and providing the updates to the team.
• Project responsibility for the specific activities or process within the CAM.
• Training of the new joiners, coaching/mentoring to team members/tenure member/new joiners
• Accountability for critical work task which impact the clients & Employees directly.
• Responsible for implementation of process improvement.
• Collaboration with stakeholders and end client to finalize the solution, for delivery on time with agreed quality standards for
Level 1 and Level 2 Appeals.
• Research, Process and take determination (decision) on claims & appeals (Level 1 and Level 2), using number of resources,
such as Total Benefit Administration, Citrix, Lotus Notes, Mainframe, HRO Maestro & Control D, client plan document, SPDs
(Summary Plan Description) & client guidelines.
• Documentation (after reviewing the claims and appeals by researching all the details going through the multiple applications,
CAM takes the determination in accordance with the US Healthcare Plan Provisions and sends the determination
(denial/approval/compliant, non-compliant letters) letter (in word document) to the employees.).
• Accountable for claims audit, review of the letters to associates/employees before mailing.
• Processing of claims, appeal, enquires & complaints for the designated group of clients. • Completion of claim and appeals
with in ERISA timeline.

Since January 2014 to January 2018: Alight Solutions (FKA AON Hewitt) as Benefits Operations Analyst (BOA)
in Health & Welfare Domain

Key Result Areas:

• Process claims, appeals, inquiries and/or complaints for a designated group of clients.
• Complete their assigned claims and appeals within ERISA timeframes.
• Interact with the Client, Benefit Centre, Plan Management, Connections, Health Plans, and Providers.
• Assume project responsibility for specific activities or processes within the CAM/BDRT, such as training, reporting, or
documentation projects.
• Research claims and appeals using several resources, such as: Citrix, Lotus Notes databases, client plan documents/SPDs, and
client guidelines.
• Audit claims for quality and training of associates. Reviews the letters for the associates before mailing to the employees.
• Collaborates with onshore team and SME to ensure timely delivery within agreed quality standards and provides timely
solutions. DA is responsible for training, reporting and documenting projects.

Since November 2013 to December 2013: AON as Senior Team Member in Health & Welfare Domain

Key Result Areas:

• Additional responsibility was mentoring and coaching new hires.
• Providing daily team production report to the Operations Manager.

Since December 2011 to October 2013: AON Hewitt as Team Member in Health & Welfare Domain

Key Result Areas:

• Dependent Verification Services (DVS) to verify eligibility among active, inactive, retiree and COBRA populations. Ineligible
dependents are removed from coverage as quickly as possible which reduces the extra cost of the employer.
• Manual Audit of participant's dependents & make decision whether they are eligible to get insurance benefits.
• Understand client values & maintain all SLA per the process requirements.
Education

• Master of Computer Applications (MCA) from IGNOU in 2015

Personal Details

Date of Birth: August 19, 1989 | Languages Known: English, Hindi & Punjabi
Current Address: B-8, Siddhartha Nagar, Ashram, New Delhi, 110014