SUMMARY

• Results - driven professional offering a progressive, more than eight years career in Healthcare information technology that involves complete Software Development Life cycle from analysis, design, coding, testing & implementation of software applications using Edifecs EM platform, B2B SAP Sybase EDI Server.
• Provided technical and business consulting, training, and ongoing support to industry-leading customers in Healthcare. Experienced business analyst in creating Business Requirement, Functional Doc, design Doc and User Test cases.
• 8 + years of system analysis experience in Healthcare space working with Data and Business users in analyzing, gathering requirements, developing and testing maps, designing/testing EDI systems, interacting with trading partners in laying standard specifications for various transactions for both Inbound and Outbound EDI mapping
• Deep understanding in Software development methodologies - waterfall, agile and SCRUM
• Experienced in SQL queries, Store Procedure, Database functions to develop, implement, and utilize databases to extract data using ETL (SSIS).
• Experienced in designing tools (Lucid Chart) for creating various UML Diagrams like Use case, Activity Diagram, BPMN, and ER- Diagram. Experienced in requirements definition and functional application design, including user stories, use cases, wire frames and business requirements documents.
• Deep understanding in ICD 9/ICD 10, CPT/HCPCS, revenue and NDC code, HEDIS matrix. Experienced with claim analysis and adjudication for Medicare Advantage, ACA Enrollment management using HIX and Medicaid Managed Care systems. Provided business consulting for Medicare Encounter Data reporting processes using EDPS, Risk adjustment using RAPS and CMS Edge Server submission for ACA enrollment.
• Machine Learning using Python Scikit learn and models - linear regression, decision tree, KNN, SVM, KNN etc

TECHNICAL SKILLS

Platforms: Windows Server 2014

Software Tool: EDI Server, EC Gateway, HIPAA Accelerator, Edifecs EM, Edifecs XEngine/XEServer, Edifecs Transaction Manager, Trizetto FACET/QNXT Suite, Python scripting, MS SQL, SSIS/SSRS

Managed and SSL File Transfer: Linoma and Connect Direct, Global Scape

Mapping Tool: SAP Sybase EcMap 5.2.8/5.0/4.25/4.01/2.9 , Edifecs map Builder and spec builder IDENotepad++, Ultra Edit, XML Editor

Packages: MS-Office, Confidential Mercury Test director, PVCS, MS-Visio, Ultra Edit, R-studio and Gephi, Power BI, Microsoft office products - Excel, word and outlook, UML

Development Tools: Python notebook (Anaconda), Visual Studio/C#, Machine Learning using Python Scikit Learn (NumPy, SciPy, Pandas)

Applications: Medicaid claims processing systems and data applications; CMS requirements compliance; Edifecs Operations Rules Product Implementation; Multiple State Medicaid Programs (OH, AL, CT, CIGNA) BI Information exchange; ICD-10 Upgrades; Upgrades; Texas NPI provider project; UAT testing

MMIS Subject Areas: Claims, TPL, etc.

Methodologies: Agile, SCRUM, Waterfall

Phases: Requirements Definition, Business Design, Technical Design, Coding, System Testing, Implementation

Tools: & Standards: SQL, XML Editor

Team Size: Lead teams of up to 10 business analysts and developers

Project Experience: Managed projects of up to 10 resources and project budgets of more than $1M

PMI Disciplines: Schedule Management, Risk Management, Issues Management, etc.

Industry Standards: ISO, Six Sigma, CMMi

PROFESSIONAL EXPERIENCE

Confidential, Bellevue, WA

Senior EDI Developer Analyst

Responsibilities:

• Senior EDI system Analyst on the Enrollment Management (ENR) project, Healthcare Management Administrator ( Confidential ) is utilizing the Edifecs Enrollment Management (ENR) suite for their managing enrollment for all the employer group. Healthcare management Administrator is a TPA who works in the northwest region and they have strongest provider network in this region.
• Confidential have different employers who are sending their enrollment information, in different flat file as well as in format. Confidential is converting all these formats to Edifecs common format (EEHCF) and process through ENR system and then send the enrollment details to their enrollment adjudication system Quick-Link in the backend.
• Working as Senior Healthcare EDI Analyst and QA analyst for Confidential enrollment management system; Working closely with multiple teams within Confidential, users/stake holder and vendors for implementation and day to day operations ENR.
• In charge of implementing Consumer driven healthcare (CDH), which is new addition to the Confidential ’s enrollment stack, parsing the FSA, HSA and IRA information for 834 enrollment file and then map the information to health equity’s flat file format.

Confidential, Federal Way, WA

Senior System Analyst

Responsibilities:

• Senior EDI system Analyst on the Encounter Data processing services (EDPS) project, Confidential is utilizing the Edifecs encounter management suite for their encounter reporting to CMS. Confidential has all their EDI data in Chiapas Application, we are building a SQL server staging environment to pull the data from Chiapas to the staging area, from where the data can be feed to the Edifecs encounter management suite. Edifecs encounter management suite will be handling all the CMS encounter reporting.
• We have different delegates who are sending their unpaid claims monthly/weekly to the system and we load them into Chiapas application database. The Prominence Health Encounter Transaction System (PETS) extracts the data from the Chiapas tables and runs several transformations on the data, so that it can be loaded into the Edifecs system for eventual submission to the CMS EDS and RAPS process. This Chiapas tables are organized according to the ANSI X12 837 EDI standard, identifying the header information’s and the loops. The data from the Chiapas tables is extracted into a set of staging tables that correspond to the sections of an Edifecs submission document.
• Working as Senior Healthcare EDI Analyst and Edifecs SME for Qualchoice Medicare Advantage Encounter Data Processing and risk adjustment system; Worked closely with multiple teams within Confidential, users/stake holder and vendors (Edifecs and Trizetto) for implementation and day to day operations for EDPS and RAPS submission to CMS.
• Evaluating and analyzing the Edifecs error reports provided by the vendors. Involved as SME in the error correction team and determined if the CMS rejection is caused by any mapping issue or potential data issue. Involved in supporting encounter data reporting processes for EDPS and RAPS including tracking, reporting, and resolving rejections, as well as involved in conducting gap analysis and data validation, identifying issues in data submission and cleansing claim data, for compliance with CMS requirements.
• Using SQL queries to analyze the claim data. Also utilized the SQL server reporting capabilities and excel for further data analysis.
• Created the crosswalk between the Chiapas SQL tables and the Edifecs comma separated format, for the QNXT data to feed to Edifecs EM for EDPS submission. Involved in verifying the mapping done by the SQL developer, revisited the mapping specs and worked with the developer to complete the business logic to avoid potential mapping errors.
• Provided day to day operation support to EDPS for error free submission to make sure that Qualchoice makes the best revenue generation and member retention for their Medicare Advantage program, while providing support to the secure file transfer between different sub systems within Qualchoice and CHI by Global Scape scripting.

Confidential, Lincoln, NE

Senior IT Analyst

Responsibilities:

• DHHS - State of Nebraska implemented Edifecs Operating Rules product to comply with the CORE Phase I and II (ACA) mandates for 27x real time and batch implementation, along with the ACA implementation, DHHS wanted to modernize their EDI system from old SAP Sybase technology (EcMap, EC Gateway and ECTRP) to latest technologies using Edifecs Smart trading Platform and SOAP UI.
• DHHS EDI system at State of Nebraska used SAP EcMap 5.2.9 and EC Gateway in their existing Production environment and they wanted to move out of SAP Sybase Product as SAP declared end of EcMap life by December 2015, thus the DHHS EDI team upgraded the entire EDI channel.
• Worked as senior system consultant and Edifecs SME to support operations in the current state of the EDI channel by fixing the Trading partner connectivity issues and supporting day-to-day transaction flow within DHHS B2B platform.
• Involved in upgrading their SAP Sybase server upgrade from older Windows 2003 to Windows 2008 R2 server. Responsible for installing all the EDI software (EcMap, EC Gateway, Connect Direct, and Linoma Server) on the new VM machines and then run the regression testing.
• Involved in creating the Functional spec document for their current real-time and batch EDI transactions for claim processing, enrollment and status enquiry, by analyzing the old EDI system build using Sybase EcMap. The functional specs were used for re-engineering the EDI interfaces using Edifecs Smart trading solution.
• Involved in smoke and user testing the Edifecs Operating rule implementation using SOAP UI tool, for both batch and real-time 270/271 and 276/277 transactions.

Confidential, Seattle, WA

IT Programmer Analyst

Responsibilities:

• Worked for multiple high visible Medicaid program implementations during my IT programmer analyst role in Confidential healthcare.
• The OHMITS EDI subsystem is an interface into the Medicaid Management Information System (MMIS) for Trading Partners. The EDI subsystem allows Confidential to exchange business information with the Ohio Department of Job and Family Services (ODJFS) electronically using XML or flat file formats.
• Worked on both inbound and outbound EDI maps; the inbound interface includes health care claim transactions from providers of health care services to ODJFS, along with encounters from MCP (Managed Care Plan) to ODJFS. The outbound interface includes ERA (electronic remittance advice) from financial sub-system to FFS (Fee-For service claim) trading partners. Other outbound transactions included Application Advice, Premium Payments, enrollment and benefit payment from Managed Care sub system to Managed Care Plans (MCP).
• Worked on the OHMITS Affordable Care Act program implementations. I provided the impact assessment of the Affordable Care Act (ACA) Section 1104 requirements (Operating rules phase 1 and 2) to MITS and HPES BES team. Also worked on gathering the phase 1 and phase 2 operating rules requirements and documented functional design docs for the eligibility request/response and the claim status request/response EDI maps. Worked on updating the X12 5010 eligibility and claim status maps residing on the State’s translator, so the OHMITS could adhere to the ACA 1104 generic/explicit query and data content requirements.
• Worked on the ICD10 related changes to the claim maps to add the ICD10 diagnosis codes (primary/additional diagnosis code, primary/additional procedure codes). Supported UAT and fixed the defects as when logged to make OHMTS EDI system in compliant with ICD10.
• Worked on the My-Care Ohio Project, as an EDI programmer analyst, on the 824 inbound map and U277 outbound map. provides the encounters that were received from the EDI Translator and to be dropped in the MCP’s mailbox at BES. The U277 flat file provided details of all encounters that were processed that day and to be delivered to the MCPs.
• Involved in the OHMITS Prior Authorization (PA) program as a business analyst, worked on analysis of the PA panels, conducted JAD session to capture the requirements of the changes to the panels. There were many changes to the PA panels due to ICD 10 and ACA programs within OHMITS.
• Also involved in the EDI production support, monitoring the batch run and in-call support activities.
• Analyzed and worked on both inbound and outbound EDI maps for upgrading 4010 version of the map into 5010.
• Worked on creating some brand-new EDI translation maps for AL, claim acknowledge (277CA) outbound maps and benefit enrollment (820) Inbound and Outbound maps. Coordinated the mapping review sessions with Tech Lead, System Analyst and Project Manager. Worked on the review feedbacks from team lead and made necessary modification to the map.
• Worked on the TPL (Third Party Liability) outbound claim maps. In the TPL subsystem, the Alabama claim engine Flat file structure files were needed to be converted into outgoing X12 structure and then dropped to BCBS Alabama for Third Party insurance payment using EcGateway. Worked with TPL backend system analyst to review the mapping document for 5010 conversions; also worked with TPL system Engineers to decide the TPL file layout change for 5010.
• Designed and worked on the Capture and store (C&S) EDI subsystem, Alabama Medicaid then decided to build the C&S subsystem to store all the currently unused fields into Database as and when they received EDI files from trading partner. So, all these capture and store would then be used in future and they used all these stored data at later point of time. All the inbound 837P/D/I map created additional XML tag for the C&S EDI fields and then those fields were inserted and stored in Database when processing through claim engine.
• Involved in SAP Sybase technical analyst in Connecticut Medicaid 5010 Migration Project using SAP Sybase EcMap 5.1.6, ECTRP and EcGateway. The project goal was to move all 4010 EDI maps to 5010 version within a very tight deadline.
• Coordinated the mapping review session with Tech Lead, system analyst and Project Manager. Also worked on the review feedbacks from team lead and made necessary modification to the map. Performed Unit test cases to test the 5010 map and match the desired output as per the mapping spec. Coordinated with other team for executing the verification job to run the XML output through the claim engine and make sure that the XML file passes the backend jobs.
• Worked on batch professional and dental map for 5010 conversion, also designed the real-time claim status request and response map for Connecticut Medicaid translator.
• Involved in EDI developer role in Cigna Eagle Liberty 5010 project; helped project team to migrate all the different CIGNA claim engine formats like ACCR, HCCR, ECR, and XCCR into 5010 compliance format and meet the Feb 2011 release timeline.
• Worked with Confidential Eagle team also building new architecture plan for the EDI channel using BizTalk server- first had to convert the ANSI X12 (4010A and 5010) format into common X12 format and then the common X12 format to map into different CIGNA claim engine formats (ACCR, HCCR, ECR, XCCR). The SAP Sybase Gateway receive the split claim and convert the claim to respective CIGNA claim engine format using Edifecs map and route to specific system (Proclaim, PPN or Power MHS).
• Worked to develop the X12 common format for 4010A/ Institutional, professional and dental claims. Created new crosswalk for mapping between 837 profession 4010A and 5010 to common format XML. Received the review feedback from team lead and made necessary modifications to the crosswalk.
• Primarily given responsibility for building ECR claim engine format crosswalk and building a corresponding map of the ECR. Made required modification to the ECR copybook based on the new 5010 requirement and created new crosswalk for X12 common format to new ECR copybook format for both 4010A and 5010. Also involved in the review meeting directly with client and make necessary modifications to the crosswalk as per the client feedback.

Confidential, Austin, TX

System Analyst

Responsibilities:

• Worked as consultant for Texas Medicaid implementation, worked on few important projects during my tenure in Texas Medicaid project - NPI provider project, migration of EDI channel new integration tool, and performed as the overall system analyst to their business users and stake holders, which enabled the Accenture team to be successful in the Medicaid operation for State of Texas. Used few translator tool for mapping and B2B trading management, like BizTalk, SeeBeyond e*Gate and IBM MQ
• Involved in the multiple projects in Texas Medicaid as senior analyst, worked on development project as programmer analyst and coordinated UAT testing with stake holders.