SUMMARY

• Proficient in EDI transaction sets. Mapping, configurations and Validations
• Adapts to change, open to new ideas and responsibilities.
• Knowledge of HIPAA/EDIX12 5010 healthcare - related transactions including834, 835 and 837
• Accountable for reporting accuracy and meeting deadlines for filing requirements to be met by the organization.
• Expertise in building EDI files, templates. Testing of all the files for any potential issue/errors before sending it to production.
• Utilizing broad knowledge to recommend solutions to the client/vendor when appropriate.
• Thorough understanding and hands-on working experience with standards for medical transactions.
• Not limited to, but includes report, mapping account structure, benefit plans etc.
• Analyze and resolve all EDI issues in processes and maintain accuracy in all inbound and outbound documents and perform troubleshoot.
• Building the files and testing to validate data and benefit information, census, demographic information.
• Assist in release testing, patch updates of EDI tools.
• Knowledge of SFTP/FTP and other file exchange. Usage of PGP Keys for file encryption.
• Experience in ServiceNow tickets and tracker.
• Handling change requests and new Implementation on daily basis.
• Extensively involved with running SQL.
• Working as a liaison with client and Vendor to communicate and validate requirements.
• Mapping, troubleshooting ANSI X12, 5010 formats / Proprietary files/ Flat files, Delimited files.
• High level of productivity, reliability, responsibility, attendance, dependability, organization and accuracy/thoroughness.
• Relies on experience and judgment to plan and accomplish goals.

TECHNICAL SKILLS

TOOLS: WFN, WFC, VI, Optum, Ultra Edit, FileZilla, ORACLE DB, WLT, Claim watcher, Crystal Report, Open PGP

KEY WORDS: ACA, COBRA, DATA TRANSFER, OUTBOUND, INBOUND, MAPPING, VALIDATION, HIPAA, PAY CODES, ANSI FILE, MS EXCEL, SQL

PROFESSIONAL EXPERIENCE

Confidential, Schaumburg, IL

EDI Analyst/BA

Responsibilities:

• Manually updating and validating claim files.
• Responsible for processing EDI 834 and 837 files and generate reports.
• Responsible for developing and implementing files between the system and outside vendors and clients.
• Resolving SFTP issues
• Responsible for generating claim adjuster analysis report and auto-adjudication claims report.
• Preparing and process eligibility claim reports.
• Running SQL queries to update accounts information. uploading manual claims image into the system.
• Preparing a roaster on daily basis which stores claim analysis information.

Confidential, Chicago, IL

EDI Analyst

Responsibilities:

• Validated electronic data interchange (EDI) transactional data sets including formats, syntax, rules, and requirements.
• Assisted with the remediation of data interchange issues and errors of EDI files.
• Performed EDI analysis, research, and documentation of transactional data set requests and issues from internal and external sources.
• Produced Activity diagrams with defined swim lanes as part of claims process analysis.
• Triage on daily basis. Working on VI page.
• Sftp issue resolutions.
• Experience with Scrum and different scrum meetings like backlog refinement, sprint planning meeting, daily stand up meeting, and retrospective meetings.
• Assist with planning and implementing quality assurance needs, acknowledged and discussed with clients the potential errors with claim processing.
• Captured and defined the vision and scope of the project with the SME and the implementation team and documented them as the scope document, the Functional Requirement document and Business Specification Requirement Document by using MS Word.
• Experienced doing test release, with functionality and patch updates.
• Conducted thorough analysis of the Business Requirements and created design specification to accomplish and achieve business needs related to Healthcare EDI X12 transactions.
• Provided daily/weekly reports, metrics, and recommendations, as needed, to all Business stakeholders and management teams using MS Excel.
• Assisted in analyzing, gathering the machine generated data for insights into operational intelligence.
• Assisted writing SQL queries, to manage and extract information from a database by using MySQL.
• Provided insights into issues in the automated claim review process and assisted in the easy correlation and real-time monitoring of events across all layers and components of the claim processing chain through data analytics.

Confidential, Elk Grove, IL

EDI Analyst

Responsibilities:

• Maintaining activities and notes in the Workflow Tool and MAIN.
• Setting up benefit plans in Confidential WFN Current Version.
• Analyzing account structure, requesting template enhancement for any required modifications.
• Responsible for implementation, mapping, testing, production and maintenance of Edi files and processes.
• Mapping the connection file(s) and troubleshooting data discrepancies, involves imports.
• Account structure, creating maps and EDI files.
• Communicating regularly with the client and carrier.
• Performed ticket triage for multiple teams.
• Identified the test cases for Automation, prepare the test cases, review it with the BA and make sure that the test cases covered with the required business rules.
• Assisting clients with, custom fields, benefit plan setup, enrollments.
• Configuration WFN Benefits module. Navigating through Confidential system in order to resolve issues.
• Open Enrollment specialist role, Siebel tickets. Creating/updating HSA/FSA plans following IRS limitations.
• Staying current and educating Clients on system updates and testing to support plan benefit designs, rates, COBRA, FSA, HSA and Open Enrollment.
• Understand client business issues and concerns and recommend and implement appropriate solution.
• Dealing with SFTP, FTP, universal credentials, SQL, Access, comma delimited, v-lookups etc. on daily basis.

Confidential, Lincolnshire, IL

Benefits coordinator

Responsibilities:

• Assisting clients with a wide variety of benefit questions and plan.
• Reviewing their account and answers questions within the parameters of Confidential 's policies and procedures.
• Staying current on programs and services through ongoing training provided and by utilizing the computer-based program.
• Provide end user support & technical help to customers.
• Setting up retirement and insurance plans.
• Exchange routine information with members of client project team, including priorities, timelines, issues as they arise.