- 10+ years of combined experience in Government healthcare/hospital , Health Insurance , Health Insurance Exchange (HIX) , Asset Management , PBM , Data Warehousing and Human Health Services (HHS) environment.
- 10 years of IT experience as a Business Analyst in all the disciplines of the Product Development Life Cycle (PDLC) : requirement gathering, analysis, testing and implementation.
- Good Experience in Business Analysis and Business Modeling methodologies and Iterative Software Development Life Cycle (SDLC) using Agile , waterfall and Rational Unified Process (RUP) .
- Core responsibilities include Business Analysis , RQM , Quality Analysis , Test Analysis , Test Execution, Filing claims (In and Out patient claims) (Medical, Hospital and Dental claims) (EDI and TDC Source) , Understanding and Documenting the requirements, Test Planning, Test Cases, Test Scripts, Defect Review and Retest.
- Participating in Status calls.
- Develop and maintain complete documentation of EDI claims , encounter 835 , 837 and eligibility file formats .
- Review critical errors from EDI and paper submissions, research and correct data in system. Participating in client calls Work control/ assignment, Contract updates.
- Maintaining recommendations to the team for final decision. Laboratory (Diagnostics), Radiology, Pathology, Emergency, Surgery, Home Health, E&M.
- COB - Copay, Coinsurance, Deductible, Contractual Adjustment, Skilled Nursing Facility, Hospice.
- Sufficient knowledge towards HL7 , Data Mapping , Benefits Administration . Handle Laboratory and Rehabilitation claims billing and AR Follow up with leading insurance.
- Report, analyze, and resolve all High Cost Outlier claim denials for Medicaid , Medicaid HMO , Medicare and Medicare HMO .
- Experience in soliciting client requirements through interviews, workshops, and existing systems documentation and procedures.
- Monitored project risks and scope to identify potential problems and proactively identifying solutions to address them in advance.
- Proficient in Database Management system with SQL queries such as Update, Create, Selection expert in Query optimization for Joining and Protection.
- Have also experience with EDI , ERP and Supply Chain applications for transportation, distribution, manufacturing and retail industries. Worked on various EDI Transactions (810, 820, 850, 855, 856, 860, 997, Orders, Ord-change, desadv etc.)
- Skilled in creating and maintaining ETL specification Document , Source to Target mapping Requirement Traceability Matrix (RTM) , performing impact Assessment, and Practical JIRA , SharePoint Knowledge for managing User stories, Label, Components, Issue type, Sub task and queries.
- Experience in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
- Organized many Joint Application Development (JAD) sessions and Joint Requirement Planning sessions (JRP) , walkthrough, Interviews, Workshops and Rapid Application Development (RAD) sessions with end-user/clients/stake holders and the IT group
- Teaming with all stakeholders to build 'as-is' and 'to-be' business process flow documentation using Microsoft Visio , as well as conduct gap/deficiency identification and analysis , including cross functional members .
- Knowledgeable of the Health Plan Employer Data Information Set (HEDIS) , as well as standards and reporting requirements for Medicare , Medicaid , and applicable state plans .
- Performs HEDIS documentation , coding, reviews and audits medical records for Hedis measures and reporting to CMS to improve HEDIS STARS .
- Experience in Bio Banking and LIMS for data representation .
- Elicited the Requirements using techniques such as Surveys, Questionnaires , Interview sessions, Brainstorming sessions, Root cause analysis , Document Analysis , cost benefit analysis , SWOT analysis , GAP Analysis and JAD sessions with Internal and External Stakeholders .
- Worked closely with the deployment team for roll out the project - external releases, packaging, distributing, installing, user assistance, beta testing , migration of software and data .
- Also worked on Application overview document (AOD) .
- Created Project management plans for managing on-time delivery using MS Project along with writing test cases, unit and systems integration test plans in Test Director.
- Prepared Annual Report of Clients Financial status .
- Handled the financial and operational issues of multiple stores across the country.
- Mapping the Client requirements with Oracle standard functionality and finding the gaps and delivering the solutions in term of Customizations.
- Conducted User Acceptance Testing (UAT) .
Environment: User Acceptance Testing , SWOT analysis and GAP Analysis, Rapid Application Development (RAD) , EDI X12 , ICD 9 and 10 , HEDIS
HEALTHCARE: Claims, EDI, ICD, SDLC, Business Analysis, Documentation, Requirement gathering, JAD, MS VISIO, RATIONAL, VISIO, TESTING, CLAIMS PROCESSING, Financial Analysis, Financial Management.
Confidential, Arlington, VA
- Developed and updated HL7 interfaces for HIS and ancillary apps and involved in source mappings and translation tables .
- Supported EPIC message processing with Record Viewer functions.
- Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction , Code set and Identifier aspects of HIPAA .
- Involved in GAP analysis , mapping , implementation , and testing for processing of Medicaid Claims . Worked on EDI transactions : 270, 271 , 835 , and 837 to identify key data set elements for designated record set.
- Validated 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270 / 271 (Eligibility request/Response) and 834 (Enrolment/ Dis-enrolment to a health plan).
- Performed AS-IS and TO-BE analysis for EDIFECS Standards - HIPAA 5010 Database Setup for new version releases. Documented proposed changes and coordinated development, testing and production release environments, including end-to-end testing.
- Create wireframes using Axure RP Pro based on collaboration with use cases and Visio flows .
- Exposed to using ICD 9/ICD 10 / ANSI / HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.
- Streamlined Claims ( 837 EDI X12 ) Migration project by gathering functional specifications in Edifecs .
- Developed data flow, work flow, process flow and entity relationship diagrams in MS Visio, and analyzed them to create "AS IS" and "TO BE" scenarios.
- Interacted closely with QA team in different phases of testing such as System testing, Functional testing, Regression testing and Integration testing for Quality Analysis using Quality Center and resolving the issue assigned on JIRA .
- Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA .
- Acted as a liaison between business area subject matter experts (SMEs) & developed teem throughout all the phases of SDLC , starting from inspection to transition phase of the life cycle.
- Created Data Flow Diagrams (DFDs) , ER diagrams for data modeling and web-page mock-ups using MS Visio for acceptance from end users.
- Assisted in Change Management and Release Management by requesting, implementing and evaluating changes to the system using Rational Requisite Pro and recording defects using Quality Center.
- Reviewed the Joint Requirement Documents ( JRD ) with the cross functional team to analyse the High-Level Requirements.
- Created various artifacts such as BRD , Functional requirement documents (FRD), Requirements traceability matrix (RTM).
- Prepared and maintain Business Rules Spreadsheets ( BRS ) identifying Rules, Triggers and corresponding data fields from Legacy to target CRM application .
Environment: JAD , Microsoft office, rational clear quest , quality center, rational requisite pro , UML methodology , oracle, database
- Interfaced with the IT division and business to address ongoing business needs.
- Prepared process flow documents capturing the defined SOP (Std Operating Procedures) for Application Outsourcing (AO) endeavors.
- Created and maintained project plan. Review the BRD , FRD , SRS , High level Design Documents, Detailed Design Documents and Requirement Matrix and prepare WBS .
- Involved in Testing Outbound Transactions
- Collaborate with SMEs from Regulatory , Clinical and Quality to integrate data, including assessment of source and target properties and product dictionaries to align with Sanofi and FDA Regulations .
- Configured the standard SFDC objects and created custom components as per the requirement.
- Created new custom objects, assigned fields, designed page layouts, custom tabs, components, custom reports.
- Business / Functional Analysis of the Clinical Data Management Applications (EDM, RDC (TAO-Trial Access Online), SMT , I- Review , PRS , IBISecg , DLS , PC Imaging , EmBARC . The tools help to support the IT part of the Life Sciences (like Clinical Trail and Discovery).
- Involved in Order Management and Inventory Modules.
- Developer and author of BIM (Business Integrated Model) for AMPs , IPL , PPRS , PES Serialization project .
- Developed user stories in EPC (Event Process Chain) .
- Used ARIS tool for Manufacturing Execution System and Production Management for Shop-floor production of pharmaceutical products.
- Also worked on the implementation of Incident Management, Problem Management, Change Management, Event Management, CMDB, Reporting and Service Catalog in ServiceNow.
- Prepared BRD (Business Requirements Document), FRD (Functional Requirements Document) and N-FRD (Non-Functional Requirements Document).
- Effectively managed the hardware and software assets through their lifecycle using the procurement module.
- Managed procurements of complex IT products and services via RFPs , IFBs , RFQs , and single / sole source methods .
- Participated in sprint planning with PM/Dev/QA to conclude the User Story points and the effort estimates.
- Strict adherence to principles of Good Clinical Practice , Good Laboratory Practice and Good Manufacturing Practice and ISO standards . Extensive knowledge of SDLC , clinical research ; knowledge and familiarity with 21CFR11 and EDC systems .
- Conducts coverage analysis of clinical research trial procedures to delineate standard of care and research procedures; reaches out to research site to assist in determining charge direction.
- Reviewed statistical data on HEDIS measures and manages special projects that are related to disease prevention, and quality improvement.
- Used ETL to map data and assemble data repository and created data marts .
- Generated and designed reports for HEDIS specifications to analyze complex data through internal databases.
Environment: SFDC , ARIS Business Architect suite, HP Quality Center ( ALM ), ARIS Business Designer and Publisher, Mercury Quality Centre, VMobile , Exploria , HP Quality Center, QTP 8.2, 9.0 , VB Script , Java , J2EE , Oracle, Visual Basic, MS-Office, Windows XP / 2000 / NT , Chrome, Quick book, EDI , HIPPA , . Net , TSD , SQL , CMMI , Oracle 9i , Oracle OBIEE , Six Sigma , UAT .
- Through review of Implementation guide and coordinated analysis to document companion guide for 5010 for EDI transactions .
- Conduct Gap Analysis by identifying existing technologies, create and document the end-user's AS-IS workflow and TO-BE business processes to better understand the mechanics of the existing system.
- Responsible to create different data flow diagrams and UML diagrams to describe the overall EDI transaction sets for different claims .
- Conducted various sessions to demonstrate 5010 impacts to all the downstream interfaces for a given EDI transaction .
- Identify, organize, and document the BRD's , interpreting them into FRD's and SRS documents and also used Caliber RM for defining and managing requirements.
- Prepare Test Data for 837I / P, develop test scenarios based on the BRD and Functional Specifications for 5010 .
- Involve in testing the loops, segments and elements in 837P and 837I based on the test scenarios.
- Actively participate in daily scrum meetings while updating the daily status.
- Created High Level Test Scenarios , Test Cases and Test Scripts for Data Hub requirements as described in RSD (Requirement Specification Documents) and DSD (Design Specification Documents) as well as HIPAA .
- Exposed to using ICD9-ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, and Reimbursement methodology.
- Gathering business requirements for ICD 10 Groupings/ classes pertaining to maintenance process, ICD 10 business rules remediation process, Medical Claims Processing System (MCPS) .
- Assisted in installation and testing of CIGNA's call center product iView on SQL server. • Assisted in establishing the procedure for back up of DB2 and SQLServer databases/users in QA environment .
- Responsible for using best practice PMO methodology to develop project plans to fit the stakeholders/sponsor's needs and deliver on desired outcomes.
- Provide a full range of health care services to business clients, enrolling and assisting with applications and regulations for the Affordable Care Act .
- Good Extensive knowledge of subprime mortgages and relative concepts in debt-service coverage ratio and loan to value ratio ( LTV ) for enhancing the insurance market.
- Worked toward processes such as claim Adjudication and claim Reimbursement .
- Determined which claim system to interact with to display data on the UI.
- Interacted with claim adjudication , claim reimbursement and billing , banking SMEs to finalize business requirements.
- Proactively communicated and collaborated with the internal/external business community and the IT organization to analyze information needs and functional requirements.
Environment: Agile/Scrum, Claim Center , DB2 , ETL , SQL Server, Microsoft Visio , HP Service Manager, procurements, Oracle EBS 11.5.10 (Oracle Inventory, Oracle Supply Chain, Advance Pricing), CRM , DML , HEDIS / STARS , CSS, VBA , Informatica Power Center 9.1/8.6, Java, .NET, Business Objects, Service Now.