EXPERIENCE SUMMARY:

• A dynamic professional having over 15 years of total experience in IT industry.
• Recent 12 years of experience under Business Analyst, Business Systems Analyst, Product Owner & Team Lead profiles in US Healthcare Domain (Provider including Inpatient & Outpatient, Payer, Pharmacy Benefit Manager, Health Insurance Exchange, BPO Services, Data Analytics, Revenue Cycle Management and Payment Integrity).
• Initial 3 years of experience into software coding using Microsoft technologies.
• Expertise in full software project / product life cycle implementation, upgrades, production support, cut - over & migration.
• Proficient in analyzing information system needs, evaluating end-user requirements, custom designing solutions and troubleshooting for complex information systems management.
• Skilled in idea generation, idea evaluation, concept development and market strategy creation.
• Demonstrated abilities in streamlining, re-engineering existing business processes.
• Participated in building proof of concept (POC) for potential new solutions and technologies.
• Command in requirement elicitation, requirement analysis, use case development, wire framing, process flow diagrams, requirement documentation (business requirements document BRD, software requirements specification SRS, functional requirements specification FRS, product requirements document PRD ), requirement validation, requirement management. Requirements include business requirements, market requirements, functional requirements (FR), non-functional requirements (NFR) and UI requirements.
• Experience in writing epics & user stories, maintaining product backlog & sprint backlog, sprint planning and sprint review.
• Interact with designers to understand system limitations.
• Help programmers during system development if they need some clarifications.
• Help QA team to write test scenarios. Review QA test cases, RTM & provide feedback.
• Competence in integration testing, system testing and user acceptance testing.
• Conducting meetings with management, vendors, users and other stakeholders to discuss issues, risks and assign actions to specific work stream owners.
• Monitor progress of the project / product as per schedule and ensuring timely delivery.
• Assist in preparing user manuals and to organize end user .
• Working experience with presales team in writing, responding to RFP and in creating marketing collateral (slides deck, brochure, sales card).
• Exposure to project management (scope, resource, scheduling, estimation, risk, communication and configuration management) / product management (setting product vision, communicating vision to stakeholders, developing strategic plan, creating and maintaining product roadmap).

TECHNICAL SKILLS:

Platforms: Windows, Windows server, AS/400

Relational Databases: SQL server, Oracle, GCP

Version Control Software: Visual source safe (VSS), Team foundation server (TFS), SVN

Programming Languages: C#, PL/SQL, T-SQL, XML, HTML, JavaScript

Software Services: Web service, Windows service, WCF

Software Testing: Test scenarios, Integration testing, System testing, User acceptance testing

PROFESSIONAL EXPERIENCE:

Confidential

Business Analyst

Responsibilities:

• Member dashboard displaying all historical HCCs (and its associated diagnosis) & whether they are recaptured or not, potentially uncaptured relevant conditions etc. Forecasts HCC Recapture Rate by comparing patients’ current year diagnoses with prior year’s diagnoses. Predictive Modelling by suspecting conditions based on Rx, DME and related conditions.
• Summary dashboard displaying recapture rates, total HCCs captured, unrealized revenue, average RAF, overall Medicare part C revenue.Helps in identifying potential gaps in care or dropped diagnosis codes between data collection periods, identifying providers and members who most likely need risk adjustment, educating providers on their performance in capturing HCCs, keep special eye on members whose HCCs is dropping etc., stabilizing risk adjustment revenue year over year, ensuring care is provided to meet the patient’s clinical needs

Confidential

Business Systems Analyst, Product Owner

Responsibilities:

• Get client’s data in flat files as per defined input data specifications.
• Reading service reads the data from flat files into the database.
• Validation service validates the data against the Rules engine.
• Analytics service analyzes the data on variety of algorithms and KPIs.
• Interactive real time dashboards and drill down reports provides data visualization in tableau to showcase descriptive analytics (tells what happened in the past), diagnostic analytics (tells why did this happen), predictive analytics (what is most likely to happen in future) and prescriptive analytics (recommends actions to take to affect those outcomes)
• Claims Analytics Integrated with Audit Framework: For Providers - Improve claims quality through clinical documentation improvement, coder accuracy &, and up to date system rules. For Payers - Decrease overpayments by updating system rules.
• Reimbursement Analytics: Focusses on effective denial management
• Recovery Analytics: Improve medical accounts receivable (A/R) management and cash flow

Confidential

Business Systems Analyst, Product Owner

Responsibilities:

• Manage clients, locations, rooms, staff, billing providers and payers | Security | Manage practitioner work schedule & appointment types | Patient appointment scheduling | Patient check-in and registration | Electronic health care eligibility benefit enquiry (EDI 270) and response (EDI 271) | Electronic health care claim submission (EDI 837) | Check electronic health care claim status request (EDI 276) & response (EDI 277) | Health care claim payment / advice (EDI 835) | E-Signature & Inter office communication | Scan, fax and print capability | Follow-up reminders & Follow-up alerts & referrals | E-billing and coding | Complete audit trail for compliance check.
• Improves sharing of patient’s protected health information (PHI) during transitions of care. | Enables patient to learn more about their health and wellness. | Supports the ability for patients to collect, store, manage and share their medical records and health information. | Physicians have the ability to send selected patient health information to a patient or a designated PHR if both parties agree to opt in. | Send reminders to patients for preventive or follow-up care.

Confidential

Business Analyst

Responsibilities:

• Delivery of APCD data as part of state mandate which includes medical claims, pharmacy claims, dental claims, member eligibility, provider, product data files as per their defined data specifications. AHRQ is using APCD data for improving health care affordability, efficiency, and cost transparency (by monitoring cost trends). States use their APCD data to compare price and performance of providers within their States and across States, measures for use with these data need to be developed and refined, and the data themselves need to be standardized
• Delivery of, provider, medical claims, pharmacy claims, CMS supplemental, Labs, Financial, IBNR (incurred but not reported) data to Clinigence Health for - a) cost evaluation and quality performance on clinical and claims data, b) reducing waste, clinical variation and unnecessary costs using advanced predictive analytics and c) maximizing ROI.

Confidential

Business Analyst

Responsibilities:

• Built data quality rules for Medical Claims, Medical Claims History, Pharmacy Claims, Dental Claims, Transportation Claims, Member Months and Member Spans. These rules help in data auditing and data improvement.
• Episode payment and utilization by episode definition (b) PAC evaluation - Identify best first PAC setting, Identify best patient pathways (c) Readmission evaluation - readmission rate variation by first PAC setting, readmission cost (d) Risk adjustment analysis - how different risk factors (patient characteristics, chronic conditions etc.) impact episode cost and readmission rate (e) Physician performance evaluation by bundle/ discharge disposition etc.
• Capable to perform the following functions relative to the health plans:
• Integrated medications database, Customizable templates for different specialties, Electronic patient encounter documentation, E-Prescription writer, Patient medical history, Drug interaction checker, Decision support, E-lab orders and results, Reporting

Confidential

Business Analyst

Responsibilities:

• Following enhancements within Pharmacy claim adjudication engine: a) Capable to store ICD - 10-CM/PCS code sets in addition to ICD-9-CM code sets at the database level b) Capable to display ICD-10-CM/PCS code sets in addition to ICD-9-CM code sets at the UI level b) Maintain bi-directional mappings between ICD-9-CM and ICD-10-CM/PCS code sets c) Capable to adjudicate the incoming NCPDP (national council for prescription drug programs) transaction request containing either ICD-10-CM/PCS code or ICD-9-CM code. e) Capable to response back the NCPDP transaction with either ICD-10-CM/PCS code or ICD-9-CM code.