PROFESSIONAL SUMMARY:

• Result oriented healthcare technology professional with a versatile experience in healthcare payers systems as a Product Owner, Business Configuration Analyst, Business Systems Analyst and data modeler.
• Specialized in product management, configuration - design, requirement gathering, analysis, elicitation, and business process modelling and risk assessment.
• Proven ability to implement product development strategies that support business and Financial objectives.
• Recognized as an expert in applying business concepts into product management decisions.
• Proven track record as Professional Scrum Master with Domain and Technical skills to Implement Agile framework in a healthcare project.
• Exceptional team leadership skills to effectively mentor, motivate and empower team members.
• Think strategically at executive level, implement change/process improvement, in corporate innovation and implement strategies throughout all levels of the organization.
• Excellent problem solving, effective communication, sound decision making and leadership capabilities along with interpersonal skills to collaborate with Stakeholders.
• Worked as an implementation consultant for Commercial, Medicare, Medicaid, Blue cross plans.
• Having very strong domain knowledge of US health Insurance plans like: HMO, PPO, POS, EPO, Indemnity plans, CDHP Plans - FSA, HRA, HSA, Medicare, Medicaid, COB and other functionalities.
• Expertise in Health insurance claims like 837I, 837P, UB04, HICF-1500, Super bills, NCPDP V-D.0.
• Having a sound business rules knowledge of EDI transactions, process and their implementations like 837,834,835, 20, 276-277, 270-271, 835, 999, 997, 277CA, TA1.
• Sound knowledge of encounter data reporting to CMS for Medicare-Medicaid (MMP) plans.
• Primarily focused on domain areas like: Claims Preprocessing - Post Processing, Clinical Editing, Enrollments (through Exchanges, State or CMS), Benefits (Plans Configuration), Workflows rules, Billing and Pricing Contracts.
• Worked for Health Insurance Exchanges (Public and Private) regards to PPACA act.
• Good functional knowledge of eligibility determination based on State mandated rules for Government sponsored health plans (Including the process of SSAP, Federal Hub, IRS and other sources)
• Well familiar with Scrum framework of Agile Software Development and currently working on the same environment.
• Involved into grooming sessions with developer, scrum meetings, sprints, review, user stories development/walk-thru and demos.
• Expertise and good understanding of ANSI X12, True XC, XC, XPF and MMS Keyword files to understand or deploy the business rules.
• Good interpersonal skills, commitment, with a quest and zeal to learn new technologies and undertake challenging tasks.
• Having an Extensive knowledge of FACETS 4.71 and 5.01, 5.30, 5.50, 5.7R2
• Workflow configuration for Confidential, which includes configuration of Workflow Queues, Roles, Routing rules, Routing Reasons, Notes, Images routing, claims testing, Images testing and more.
• Processing Control Agent with combination of Workflow routings to autoroute the claims.
• Claims end to end testing from EDI-XC-FACETS prospective troubleshoot and triage the root cause of wrong claims payments.
• Proof of Concept and Implementation the solutions of Auto Images routing into FACETS from TIBCO rules at Member and Subscriber level, including FACETS SA configuration of System components.
• Membership maintenance (MMS) jobs and implementation of Member files from CMS into FACETS based on the TRR request and response.
• Billing related data to troubleshoot for wrong billing which including the members enrolled through Exchanges, Re-bill members, Alternate funding billing and other informations.
• Providers intake process with Confidential to implement into FACETS based on TNERG logic(Tax-NPI-SSN-REMIT-Group), this includes the FACETS intake XPF process with business to implement providers data into FACETS.
• Extensive knowledge on Claims backend-Front End, Benefits(Medical Plan- Front End - Backend), Billing Modules, Workflows, Membership, Providers and Pricing to troubleshoot the claims.
• Troubleshooting skills to triage Claims, Benefits, Membership, Providers, Pricing, Billing from their batch prospective like CLMU, CLMM, CLEU, XPF, MMS, BIL0,BLXP, BLAF etc.

CURRENT PROJECT SUMMARY:

Confidential

Business Systems Analyst

Responsibilities:

• Worked with Provider’s team to intake and manage the provider’s data for from external alliance partners to consume in FACETS tables.
• Worked a liaison between Business and IT for provider business rules to implement.
• Involved into end to end testing of Provider’s intake and their claims processing.
• Analysis of system requirements and Defect Triaging.
• Analysis the requirement of Configuration and apply in the FA product for providers
• Involved into unit testing, system testing, and test designs for the provider related projects.
• Involved in Mentor peers in various FACETS application modules, functionality which includes benefits configuration, providers pricing, claims intake (online and XC) and provider’s configuration.
• Involved in troubleshoot the issues based on technical environment and technology - Trizetto FACETS.
• Involved into performing issue triaging, tracking, test case, creation, execution for different sets of business related data of providers XPF data.

Confidential

Product Analyst

Responsibilities:

• Involved into Confidential Legacy Claims to transform in Trizetto FACETS product implementation with new rules.
• Involved into data mapping, data analysis and data modelling of Confidential to FACETS mapping.
• Involved into core Claims Workflow requirements gathering, analysis and documentation of Medicare, Medicare and Commercial LOB.
• Involved in Core Claims requirements, Processing, Edits and analysis, design of TZ Facets.
• Worked a liaison between Business and IT for the Trizetto FACETS solutions related to Claims, Membership, Benefits and Pricing.
• Analysis of system requirements and Defect Triaging.
• Analysis the requirement of Configuration and apply in the FA product.
• Involved into unit testing of Workflows, Benefits Configuration, and Provider Contract Configuration in Facets.
• Involved into implementation of full cycle of Claims -workflows rules for Analysis, implementation and testing.
• Involved in Mentor peers in various FACETS application modules, functionality and SQL server management tool.
• Involved in troubleshoot the issues based on technical environment and technology - Trizetto FACETS, . Net framework, SQL Server Management, Web Services, SQL queries, TIDAL job scheduler, EDI, XC.
• Involved into performing issue triaging, tracking, test case, creation, execution for different sets of business related data of claims like XC claims file, EDI data, MMS Keyword files and other membership functional data.