R Swamy R Reddy PMP AI Healthcare

- Lead healthcare coding compliance and uphold data integrity in alignment with ICD and CPT standards established by Oman’s FSA. - Played a key role in the design, implementation, and integration of ICD and CPT coding structures during the hospital’s operational setup. - Collaborate with the IT division to ensure seamless integration, testing, and optimization of coding modules within the hospital information system. - Support the claims and revenue teams in efficient claim submission and resolution through the Dhamani platform, minimizing rejections and delays. - Identify and resolve coding discrepancies and claim issues, ensuring accuracy, compliance, and timely reimbursement. - Partner with clinical and management teams to maintain alignment between clinical documentation quality and financial governance. - Contribute to service pricing, package structuring, and negotiations for empanelled insurance and corporate service agreements. - Develop and implement policies and process enhancements to strengthen compliance and streamline revenue cycle operations. - Conduct comprehensive internal audits to assess coding accuracy, regulatory adherence, and performance improvement opportunities. - Serve as a strategic liaison between clinical, administrative, and IT departments, facilitating integration and operational efficiency across functions. - Driving strategic initiatives to strengthen Clinical Documentation Integrity (CDI), enhancing documentation quality, physician engagement, and the accuracy of clinical and financial data.

- Led enterprise-level AI integration across Revenue Cycle Management processes, enhancing speed, accuracy, and reimbursement outcomes in clinical documentation and coding workflows. - Designed and deployed AI-powered CDI solutions to auto-flag documentation gaps, generate smart physician queries, and support accurate DRG assignment and audit readiness. - Implemented auto-coding tools capable of extracting ICD-10, CPT, and procedure codes from unstructured EMR data, significantly reducing claim preparation TAT. - Embedded payer-specific rules and denial prediction logic into AI systems, improving first-pass claim acceptance rates and reducing reimbursement delays. - Collaborated with clinical, coding, and IT teams to build scalable AI solutions integrated with EMR platforms and revenue cycle tools, ensuring workflow harmony and user adoption. - Developed AI-driven audit alert systems to proactively identify high-risk charts for FWA, compliance breaches, and RAC audit triggers. - Established performance dashboards for real-time insights into CDI metrics, coder productivity, denial trends, and DRG shifts—supporting strategic decision-making. - Trained cross-functional teams in leveraging AI capabilities for clinical documentation, claim lifecycle, and compliance reporting. - Led UAT, validation, and enhancement cycles to ensure AI model accuracy, relevance, and regulatory alignment. - Partnered with vendors and health-tech startups to customize AI algorithms for multispecialty hospital use cases, from surgical coding to chronic condition profiling.

Manager – Clinical Documentation & DRG Programs Aster Group of Hospitals (400–500 bed facilities) - Spearheaded the implementation and optimization of a high-impact Clinical Documentation Integrity (CDI) and Diagnosis-Related Group (DRG) program across four hospitals, aligning with Dubai Health Authority (DHA) protocols. - Led end-to-end DRG transition strategy including physician training, interdisciplinary coordination, and CDI staff onboarding—resulting in proven improvements in clinical and operational outcomes. - Designed and institutionalized policies and procedures linked to CDI metrics, achieving measurable gains in DRG revenue optimization and streamlined resource utilization through coordinated physician and nursing engagement. - Oversaw an integrated CDI-DRG ecosystem involving Pre-Authorizations, clinical documentation, billing, and claims operations, ensuring seamless patient throughput and revenue cycle alignment. - Conducted DRG and fee-for-service analytics, including DRG weight, base rate, and cost factor (CF) assessments—contributing to strategic payer negotiations and revenue forecasting. - Monitored specialty- and physician-specific DRG billing patterns to drive improvements in Average Revenue (ARR) and Case Mix Index (CMI). - Provided strategic advisory support to pre-auth, coding, and case management teams on improving claim flow efficiency and reducing patient Turnaround Time (TAT). - Successfully led and closed regulatory and payer audits (DHA and insurance recoveries), preparing defensible appeals with clinical documentation, coding standards, and regulatory compliance. - Delivered Fraud, Waste, and Abuse (FWA) training across hospital functions, enhancing audit readiness and organization-wide revenue integrity. - Collaborated with IT to re-engineer the electronic medical records (EMR) workflow, automate code capture, and reduce claim processing TAT using cost-effective, technology-driven solutions.

- Directed large-scale training initiatives for both new hires and on-the-job employees to support ICD-10 transitions and performance upskilling. - Conducted comprehensive training needs assessments based on employee performance metrics, project goals, and organizational strategy. - Designed and delivered modular training programs tailored to identified needs, using a mix of in-person sessions, blended learning, and digital tools. - Spearheaded client-priority training engagements, ensuring quality delivery and smooth transition of newly onboarded projects to production teams. - Facilitated interactive training workshops and knowledge transfer sessions, while continuously monitoring effectiveness and impact through KPIs and quality outcomes. - Led regular "Train-the-Trainer" programs, enhancing facilitator skills in alignment with organizational learning objectives. - Fostered strong collaboration with client stakeholders, team leaders, and project managers to align training outputs with strategic project goals and client expectations. - Delivered timely learning performance reports and insights to executive leadership, supporting continuous improvement and workforce readiness. - Managed the L&D budget efficiently by optimizing training tools, delivery methods, and resource allocations to drive maximum ROI. - Enhanced workforce capabilities, job performance, and long-term productivity through scalable training strategies that supported enterprise-wide goals.

- Led enterprise-wide ICD-10 implementation across coding, billing, and documentation teams, ensuring seamless transition from ICD-9 while maintaining accuracy and compliance. - Developed project roadmap and training strategy for coders, physicians, and clinical teams aligned with regulatory requirements and specialty-specific guidelines. - Conducted comprehensive training needs assessments and delivered tailored educational sessions to improve documentation quality and code specificity. - Collaborated with IT teams to update EMR templates, coding software, and reporting dashboards to support ICD-10 readiness and integration. - Mitigated financial impact during transition through proactive audit preparation, coding accuracy reviews, and continuous process improvements. - Liaised with revenue cycle and compliance teams to optimize claim workflows and maintain uninterrupted reimbursement during and post-implementation. - Monitored key performance metrics such as coder productivity, claim rejection rates, and documentation completeness to track program success. - Implemented risk mitigation strategies for coding denials and provided post-go-live support with query management and audit feedback loops. - Facilitated "Train-the-Trainer" programs to build in-house capacity for ICD-10 education, ensuring long-term sustainability and scalability. - Delivered executive updates and post-implementation reports outlining milestones, audit results, financial impact, and strategic insights.

- Conducted detailed coding & audits to ensure coding compliance with payer guidelines and regulatory standards. - Reduced claim denials by identifying documentation gaps and initiating physician queries to support accurate code capture. - Trained junior coders on specialty-specific guidelines and supported onboarding of new hires with structured learning modules. - Provided coding expertise during payer audits, helping defend claims and reduce financial recoveries. - Successfully led end-to-end ICD-10 transition projects, including coder upskilling, documentation alignment, and system readiness across multi-specialty domains. - Accurately coded inpatient and outpatient charts using ICD-10, CPT, and HCPCS systems, ensuring compliance with payer and regulatory guidelines. - Conducted training sessions and workshops for coders and clinical staff on ICD-10 standards, improving accuracy and audit readiness. - Coordinated with EMR/IT teams to align templates and workflow for accurate ICD-10 diagnosis and procedure capture. - Collaborated with CDI, billing, and RCM teams to streamline documentation-to-claims lifecycle for timely reimbursements. - Led "Train-the-Trainer" initiatives to build internal coding education capacity and support long-term coding accuracy. - Provided coding support during payer and compliance audits, contributing to favorable outcomes and revenue protection. - Created SOPs, coding guidelines, and transition documentation to ensure sustainable coding practices post-transition. - Monitored KPIs including coder productivity, accuracy rates, and denial trends to drive continuous improvement and strategic alignment.