SUMMARY:

• Results - oriented professional with good communications, team building, analysis and problem solving skills including 7 years experience in EDI Analyst & Quality Assurance Analyst, and client relationship management.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• Experienced working in Pharmaceuticals companies with Oracle Clinical Trials in FDA validated environment.
• Experienced in full System Development Life Cycle (SDLC), from requirements gathering and business case development to rollout and maintenance using Waterfall, Agile/Scrum, and Rational Unified Process (RUP) Methodologies.
• Thorough understanding and hands-on working experience with standards for medical transactions like 820 (enrollment), 834 (premium payments), 835 (medical claims payments), 837 (medical claims), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), and 277 (claim status response)
• Experienced in payer rules, requirements, governmental regulations and HIPAA compliance. Interacted with claims payment and enrollment to review, analyze and document business processes.
• Ability to educe, define, document business user requirements, managing requirements and analyzing requirements, changing requirements and translating requirements and objectives into business/technical requirements based on project scope parameters.
• Responsible for EDI strategies enabling Health Care Providers and Insurance Careers to communicate effectively.
• Experienced working with clients in the Healthcare industry. (NPI, Membership & Billing, MetaVance, EDI 837, Professional and Institutional Claim Processing, COB, NASCO)
• Proficient in the implementation of production change management techniques and service delivery disciplines
• Good Working Knowledge of HIPAA Regulations and Claims Processing.
• Created design documents like data flow diagrams, process flow charts using MS Vssio and UML.
• Strong Object Oriented Analysis and Design using UML, Rational Unified Process, Rational Rose.
• Comprehensive experience in writing Test Plans, Test Cases and Test Scripts using manual and automated testing tools from Rational and Mercury Interactive such as test Director, Winrunner.
• Actively involved in developing, executing and managing User Acceptance Testing (UAT).
• Good hands on experience testing of inquiry screens to support EDI transactions.
• Outstanding communication skills and the ability to work effectively with technical teammates in order to translate business requirements into an effective technical solution and serve as an effective communication channel between the key IT and business contacts.

TECHNICAL SKILLS:

Databases: MS ACCESS, MS SQL Server

Methodologies: RUP, OBJECT ORIENTED ANALYSIS AND DESIGN, J2EE, UNIFIED MODELING LANGUAGE

Modeling Tools: RATIONAL ROSE, ERWIN 4.0, MS VISIO

Testing Tools: MERCURY WINRUNNER 7.0, TEXTDIRECTOR 6.0

Operating Systems: WINDOWS 98/2000/ME/XP, WINDOWS NT, UNIX

Office Tools: MS WORD, MS EXCEL, MS POWERPOINT, MS PROJECT 2002/2003

Quality Management: HIPAA

PROFESSIONAL EXPERIENCE:

Confidential, Basking Ridge, NJ

Senior 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.
• Developed Use Cases, Activity Diagrams and Sequence Diagrams and other UML diagrams for a clear understanding of the project vision by using MS VISIO and Lucid charts.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Produced Activity diagrams with defined swim lanes as part of claims process analysis
• Documented and gathered Functional specifications for 837 (claims), 278(Authorizations) and 270/271 (Eligibility and Benefit Response).
• Experience with Scrum and different scrum meetings like backlog refinement, sprint planning meeting, daily stand up meeting, and retrospective meetings.
• Testing EDI Encounter Data, 837 claims data. Encounters are major data which involves checking status of claims.
• 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.
• Write high level and low level integration requirements for integrating our product with clinical editing tools, predictive analytics tool.
• Extensively involved in data analysis, data modeling, Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Conducted thorough analysis of the Business Requirements and created design specification to accomplish and achieve business needs related to Healthcare EDI X12 transactions such as 835 and 837.
• Development included the use of Test Driven Development, Extreme Programming for continuous Integration and enhancements. team creates data upon request for different teams like Encounters, Claims and 837.
• Performed User Acceptance Testing (UAT) with business users and stakeholders, gathered requirements through interviews, workshops, and existing system documentation.
• Provided clinical 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, VA

EDI Analyst

Responsibilities:

• Analyzed, transformed, resolved, and an assisted with the implementation and ongoing support of the Health Insurance Exchange (HIX) environments utilizing (Strategic planning, Business model analysis, Process design, and Systems analysis).
• Created maps & layouts for HIPAA as imposed during EDI: 837, 834, 835, 270/271, 277/275, 276/277, 278.
• Implement EDI maps in X12 and XML. Transaction sets used 820, 834, 837, 850, 855, 856, 810, 832 & 867 QA and User Acceptance Testing
• Mapped the Bloodhound tool (clinical editing tool) related data elements to the internal XML elements.
• Prepared Data files for 837, 835, 834 and 820 for Edifecs XEServer, XEngine, and Transaction Manager for UAT, QA and Vendor files testing.
• Performed business analysis, data assessment, and data mapping and gap analysis information in authoring companion guide requirements documents for the 820 payment/order remittance and the 834 health enrollment transactions in the initial implementation of the HIPPA standard.
• Involved in QA Testing of Inbound 837 Claims processing, 835 Remittance Advice, Benefit Enrollment (834) for EDI transaction sets.
• Worked on data flow diagrams, sequence diagrams, and business process models that describe how the EDI Health Care Claim Transaction set (837) is used to submit health care billing information and encounter. Designed and developed web pages to explain the requirement for technical team using XML.
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Recorded retention stored in Knowledge Link. Ad Hoc reporting, Admin for MS Project, Excel dbase and pivot tables, Clarity and MS Project Server Admin duties.
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Planned and documented procedures for data processing and prepared data flow diagrams for the application.
• Facilitated collection of User Requirements and System Requirements to create the Busines Requirement Documentation (BRD), using MS Word and MS Visio that provided appropriate scope of work for technical team to develop prototype and overall system.
• Mapped high-level to-be designs using Business Process Modeling Notation (BPMN) on MS Visio.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.

Confidential, Tampa, FL

EDI System Analyst / QA Analyst

Responsibilities:

• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus.
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
• Developed Data Mapping and Crosswalk documents.
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 834, 820, 835, 837, Dental, and HIPAA EDI Transactions across enterprise.
• Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277, 278, 820, 837P, 837I, 837D, 835 remittances)
• Develop, coordinate and support Information Technology Division on all operational requirements of FACETS claims processing system and production management.
• Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with Use Cases from the analysis.
• Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrolment and benefits, batch jobs corresponding to the claims (837) and real time transactions like 270/271/276/277.
• Worked with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using General Equivalence Mappings (GEM).
• Performed Gap Analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
• Re-engineering and capturing of EDI transactions with legacy systems Enrolment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.
• Worked in testing the professional, institutional claims processing and adjudication and validate data with facets.

Confidential, Buffalo, NY

QA Analyst

Responsibilities:

• Extensive Experience in Core Claims System in a Managed Healthcare environment
• Experienced with Test script prep, systems testing and UAT ideally in a Healthcare environment
• Followed up with the SME in every module to ensure that HIPPA guidelines are being followed.
• Involved in testing HIPAA Database, which incorporates all the HIPAA transaction sets.
• Experience with Network price-testing and figuring pricing for procedures and claims based on information inputted into Network.
• Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets.
• Involved in end-to-end testing of FACETS Enrollment Claim Processing and Subscriber/Member module.
• Write many SQL queries in order to retrieve data/check data from different tables.
• Wrote test cases in Quality Center derived from the BRD and generated a Traceability Matrix for testing purposes.
• Created Traceability Matrix to ensure implementation of all functionalities, identify all test conditions and test data needs.
• Tested the HIPPA EDI 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data on different modules.
• Involved in System testing, Regression Testing and User Acceptance Testing (UAT) manually and Automation tool.
• Managed defect tracking process, which include prioritize bugs, assign bugs and verifying bugs using QC.
• Handling/Tracking defect in the Quality center and export in to Excel by using filter.