Damodar Reddy

Projects: (Payment Assessment Calculation Engine)

Location: India

Client: Aged Care, Australia.

Residential aged care in Australia is governed by the Aged Care Act 1997 (the Act) and is subsidized by the Australian Government; the amount of subsidy is currently determined by a resource allocation instrument - the Aged Care Funding Instrument (ACFI). The ACFI assesses core care needs as a basis for allocating funding. Execution of this policy is supported by the My Aged Care system, managed by the Department of Health, and the System for the Payment of Aged Residential Care (SPARC), managed by Services Australia.

The PACE Solution will determine eligibility, calculate entitlements, fees, and advances for payments to be made to a Service by gathering circumstance, classification, and event inputs across care recipients. Entitlements are calculated for the individual-level for Care Recipient supplements, subsidies, and reductions (where applicable) as well as for the Service in line with policy and legislation. Entitlement calculations performed retrospectively.

Roles & Responsibilities

·        Pega Technical Lead for Claim and Review modules.

·        Managing a team of 6 for all operational enhancements and defects.

·        Participate in DCO sessions - Understand the requirements and guide the LBA and the client SMEs to capture the requirements, process steps and objectives.

·        Mentor and coach other Pega developers in the team.

·        Interacted with end business users directly for business issues/clarifications.

·        Distributing defects and enhancements within the team.

·        Provided technical guidance to the team wherever required.

·        Manage the key design areas of a Pega implementation.

Designation: Technical Lead

Projects: (Utilization Management)

Location: India

Client: Highmark Health Solutions, US.

Highmark is a private healthcare company based in Pennsylvania, USA. It is the largest health insurer in Pennsylvania and operate health insurance plans. In addition to this it also offers dental insurance, vision care and reinsurance.

In UM we mainly take care of multi-level authorizations for Inpatient, Outpatient and Pharmacy. Based on approvals and denials from several members like Care Manager, Pharmacist, Medical Director, etc., We send letters to Members. Here if case is denied, member has an option to appeal it by providing required documents. If it was appealed by member again, the same process continuous and Medical Director can approve or reject the appeal. If case is approved and if it is Inpatient case user can request to extend discharge date.

Roles & Responsibilities

·        Pega Technical Lead for Utilization Management module.

·        Managing a team of 8 for all operational enhancements and defects.

·        Participate in DCO sessions - Understand the requirements and guide the LBA and the client SMEs to capture the requirements, process steps and objectives.

·        Mentor and coach other Pega developers in the team.

·        Interacted with end business users directly for business issues/clarifications.

·        Distributing defects and enhancements within the team.

·        Provided technical guidance to the team wherever required.

·        Resolving Production support issues wherever required.

·        Manage the key design areas of a Pega implementation.