Sachin Chougule

Experience

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  MDIndia Health Insurance TPA Pvt. Ltd.

  Dec 2006 - Sept 2007

  Senior Executive Medical Advisor

  Role of Executive senior Medical advisor in a Health insurance Third party Administration Company. Adjudicating and processing claims of reputed client insurance companies.

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  AXA Business Services Pvt. Ltd

  Oct 2007 - Dec 2010

  Specialist: AXA Business Services

  Adjudicate and process claims against the rules and benefits stated in AXA policiesAnalyze health insurance claims for accuracy, completeness and eligibility. Skilled in Formulating & implementing underwriting guidelines, processes, workflow, application forms, etc.Proficient in managing all aspects of loss assessment and claim settlement pertaining to a wide range of Health insurance covers.Ensure timely resolution of internal and external customers for queries and complaints received. Show less

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  Care Management International

  Dec 2010 - Jan 2015

  Preparing daily workloads for staff & coordinating the daily allocation of work. Motivating the team to achieve high standards and KPI targets.Handling new client enquiries and acting as the face of the businessMentoring and training up junior and new staff. Monitoring & reporting on standards & performance targets. Arranging & chairing weekly team meetings, focusing on targets & achievements. Implementing new initiatives. Involved in the recruitment of new staff. Formulating backend clinical rules logic for eligible member identification and alert flagging as per requirement of MTM program and providing it to the IT team for implementation.Successfully worked as Subject Matter Expert for development of MTM application. Show less Project: Medication Therapy Management: Review patient medication profiles and identify pharmacotherapy issues, including drug interactions, contraindications, drug duplication, medication non-adherence and drug dosing issues. Perform knowledge transfer of Medication Therapy Management (MTM) product design to new MTM clinicians through use of a variety of communication tools. Project: Clinical Summarization: Conduct comprehensive review of clinical history and clinical data to gather/abstract relevant information in accordance with provided guidelines. Concisely summarize clinical information in a standard format. Assess gaps in care and provide evidence based recommendations with appropriate references. Complete abstraction of the required data elements in the web based tool. Project: Medical Policy Automation: Reviewing of health insurance policy bulletins and creating a database of these policies to support automation within claim processing systems for leading US health insurance companies. CPT to ICD mapping and creating rules for automation. The project includes knowledge of medical coding and experience of dealing with ICD/CPT/HCPCS codes. Show less

  • Team leader: Clinical programs

    May 2012 - Jan 2015

  • Senior Clinical Reviewer

    Dec 2010 - May 2012
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  Cotiviti

  Jan 2015 - Mar 2016

  Research Analyst

  Conduct comprehensive review of clinical history and claims data to gather/abstract relevant information in accordance with provided guidelines (US Insurance) Develop clinical rules and medical policies based on the federal and CMS update on coding for US Healthcare payers. Handle queries received from configuration analysts and testing analysts for proper functioning of clinical rules and resolve the issues. To work as a bridge between configuration, testing and medical policy developers. Also providing support to business analyst for internal projects.Providing clinical informatics domain expertise to demo development projects, conduct research, develop and implement content. Provide guidance for team of testing on proper functioning of the clinical rule in Rule Maintenance Application. Participate in internal and Client meetings. Show less

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  MediQuire

  May 2016 - Aug 2017

  Senior Functional Analyst

  Analysis of HEDIS, NCQA, PQRS, eCQM, UDS, MIPS and ACO clinical quality measure specifications and to provide support to technical team in interpretation, development, implementation, deployment and evaluation of these measures.

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  FIGmd, Inc.

  Dec 2017 - Jul 2019

  Lead Clinical Registry Analyst

  Worked as Lead Clinical Registry Analyst (QR and QCDR) for US-based Health IT organization which provides clinical data registry, analytics and data reporting solutions to medical practices, specialty societies, medical professional associations, hospitals and health systems.

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  Evolent Health

  Jul 2019 - Nov 2020

  As a Product Owner on an Agile development team, I was responsible for supporting the development process by managing story and feature acceptance, performing data analysis, and creating test data. I maintained and prioritized the development backlog, ensuring alignment with project goals. I also collaborated with cross-functional teams to develop new features and enhance existing ones, while assisting client-facing teams in understanding and explaining platform functionality.

  • Product Owner

    Apr 2020 - Nov 2020

  • Associate Medical Director, Clinical Informatics

    Jul 2019 - Apr 2020
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  FIGmd, Inc.

  Nov 2020 - Sept 2021

  Assistant Manager

  I led a team of physicians and medical coders to implement QPP and HEDIS measures at a US-based Health IT organization. I acted as a liaison between clinical experts and data mapping teams to ensure accurate extraction of clinical data from various EHR systems. I provided consultations on clinical and specialty society matters, guiding practices and American specialty societies new to quality reporting. I collaborated with IT teams to develop technical specifications and identify data points to close care gaps. I also attended weekly client calls to address and resolve queries related to clinical data and quality measures. Show less

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  CoverSelf

  Apr 2022 - Mar 2024

  Healthcare Consultant

  As a Consultant for developing a Payment Integrity platform for US healthcare payers and providers, I identify, interpret, and implement new concepts to recognize incorrect payments. By analyzing medical claim data, I discover incorrect claims and provide the necessary requirements and support to the technical team for the development, implementation, and evaluation of clinical quality measures for value-based care (VBC). I own medical policies end to end, develop coding guidelines and ensure compliance with Medicare rules, and maintain these rules according to industry updates. Additionally, I conduct demo sessions and handle queries from prospective clients. Show less

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  Innovaccer

  Apr 2024 - now

  Associate Director, Clinical Informatics