PROFESSIONAL SUMMARY:

• 19+ Yrs. of IT experience as Facets Product Consultant/ Data Architect/Systems Integration Analyst involved in Design, Development, UAT and Implementation/Conversion of Legacy systems to Facets.
• Expertise in Core Facets Modules: Provider, Membership, Accounting, Billing, Claims, Customer Service, and Workflow.
• Expertise in Facets configurations for Provider agreement Creation, Claims, Commissions and Membership areas.
• Solid Experience in FACETS batch jobs and capabilities such as setting up Run books, error logs restarts etc.
• Expertise in Facets keyword files generation and their structures such as MMS (Membership) XPF0(Provider)
• Experienced in solving Complex problems related to Facets Configuration within Provider and Claims area during Facets Implementation.
• Experienced in Agile and waterfall Methodologies and Software Development Life Cycles.
• Deep understanding of API (REST, SOAP).
• An understanding with the AWS ecosystem (Redshift, RDS, EMR, S3, EC2, Lambda).

TECHNICAL SKILLS:

RDBMS: SQL Server, Oracle, Sybase

Languages: PL/SQL, T - SQL, C++, C, .Net (C#/VB), COBOL

IDE: Visual Studio, TOAD, SQL, PL/SQL Developer

Operating Systems: UNIX - Solaris/AIX/SCO/Linux, Android, Windows, Mac

Tools: SSIS, Project, Office, Pages, Notes, Rational Rose

Methodologies: Agile, Waterfall, combinations of methodologies

Software: Trizetto Facets 2., XPF0, MMS, TCS, CareAdvance, Optum CES, HIPAA Gateway, Erwin, RUBI

PROFESSIONAL EXPERIENCE:

Senior Technical analyst

Confidential

• Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions. Worked specifically with 837, 835, 834, 270/271, 276/277
• Worked on the requirements pertaining to client requests for changes / modifications required for Texas Medicaid from stakeholders.
• Installed, integrated, and supported QNXT environments for a new line of business.
• Designed and deployed a solution to utilize QXNT web services to get authorization information from CareAdvance to QNXT.
• Completed QNXT from 5.2 to 5.4 Upgrade project. It was achieved by closely working with Cognizant team on their tasks.
• Installed and upgrade ClaimCheck.
• Worked closely with vendor to upgrade and manage whole project encounter data management for the client.
• Managed project schedule, managed resources, deliverables and key milestone during Project.
• Installed, configured and maintained HIPAASUITE product to load inbound EDI transactions like 834,837 and 277CA .
• Utilized a combination of business knowledge, technical skills, and strategic analysis to provide solutions and creative insights to critical business problems.
• Effective in multitasking and effective management of assignments/deliverables according to work schedules with strong project management orientation.

Senior Facets Consultant

Confidential

• Participated in daily IT prioritization meetings for new Facets implementation and provided effective solutions.
• Involved in creating and maintaining custom processes to create keyword files for provider load (XPF0) and member load (MMS).
• Extensively used SQL queries to retrieve various reports for different departments.

Senior Facets Application Principal

Confidential, Grand Junction, CO

• Responsible for all aspects of the Trizetto Facets Windows based systems, Microsoft Windows security access controls, troubleshooting and problem resolution for the Windows environment. Installing and managing Trizetto Facets and security.
• Collaborates with the Application Services and other IT teams to provide a stable and secure Trizetto Facets infrastructure.
• Installed and configured Facets Application Server on Physical servers
• Created Facets Regions for DEV, QA and PROD environments.
• Created jobs for Facets Batches like CLMU, MMS0, XPF0, and UMI0 in TIDAL Scheduler.
• Configured System and Runbook files as per business requirements.
• Identified Facets Patches and their dependencies as per Business requirement
• Installed Facets NetworX Pricer application on both Clustered and Standalone environments using IBM
• WebSphere Network Deployment and IBM WebSphere Application Server versions 6.0/6.1/7.0.

Senior Facets System Advisor/ Technical lead

Confidential, Los Angeles, CA

• Inside project is an ambitious initiative by CareMore and her parent company Anthem; to provide a host of services to the clients that would like to outsource the hosting of their business operations to a company which has a proven business model and is able to consistently deliver value to its customers and partners. This project has a host of products that are being integrated to deliver a common solution. These products include Access Express, NextGen, Facets and others. These products are integrated thru a common shared data layer architecture that involves membership, eligibility, billing, provider, claims, and utilization data both inbound and outbound to the shared data layer.
• I have been involved in creating the integration points of Facets with this data layer using Facets business model and integration points.
• Managed the effort for Facets upgrade . Successfully created and managed project plans to track scope, schedule, resource and budget effectively. Coordinated with stakeholders to track project changes in accordance with the EPMO processes. Organized regular meetings with project teams and business for project updates, risks, issues and action items. Implemented Agile project methodology practices across all projects.

Senior Manager

Confidential , CA

• As per the Implementation of the Affordable Care Act that was signed, Blue Shield of California has been engaged with HPS, an external vendor to handle the IFP business; both on-exchange and off-exchange. For on-exchange IFP business, HPS will receive the enrollment and membership maintenance information from exchange through 834 transactions. HPS will perform the HIPAA validations and send the 834 transactions to BSC. BSC will load these enrollments into Facets, process the eligibility and generate an 834 confirmation file (only for initial enrollments) back to HPS. HPS will process this confirmation file and send an 834 effectuation file back to exchange.
• Provided solution on Facets Post Implementation Issues and provided support for ongoing Production issues related to Facets Membership and Provider Data.
• Implemented Three way recon solution to fix data Anomalies between three systems (Covered California, HPS and FACETS )
• Designed new tables in SAS Enterprise guide to performed data analysis.

Senior Technical Analyst

Confidential, NJ

• Interfaced with business users to prepare and update Business Requirement Document (BRD), High Level Design Documents (HLD), and TDD (Technical Design Document).
• Conducted Post migration analysts to prioritized outstanding defects and system problems, ensuring accuracy and deadlines were met.
• Validated technical designs created by IT developers against functional specifications.

Senior Technical Specialist

Confidential , NJ

• Lead architect of a new Provider Automation project to automate the provider loading process that will reduce significant manual effort and decrease XC claim fall out for No provider found and subsequently increasing auto-adjudication rate.
• Worked on redesigning and optimizing the Core EDI Process.

Senior System Analyst /Tech Lead

Confidential, NY

• Developed Cactus - a Facets Interface to establish New Common Practitioners in Facets via the XPF0 Job as a core provider information system including all provider types, in or out of network. Responsible for all Cactus maintenance and enhancements to ensure the application’s expanded role.
• Managed six - member team to successfully develop a new Web Portal solution, providing Members and Providers with access to Claim, Eligibility and Benefit information. All Facets communication is accomplished through Trizetto Portal Transaction Services (PTS) - a business layer running on a web sphere environment.
• Architect/Lead Developer of a new IVR enhancement project to deliver the following functionalities:
• Additional Search criteria for Members and Providers to perform Eligibility Search using CIN and/or SSN;
• Claim Status inquiry;
• Access to Claims Information via Fax (Fax Back);
• Member access to Recertification Information;
• Request materials such as Hand Books, ID Cards, Provider Directories;
• Members’ address maintenance (Home and Mailing)
• Designed and developed AP Positive Pay Interface to extract/send Claims and Capitation check payment information from Facets to the bank, and receive/upload cleared check information into Facets from the bank.
• Lead EDI claims load-adjudication into Facets and developed a claims back-out process.
• Provide technical assistance in identifying production problems for Facets XC00 and CLMU jobs.
• Analyzed business requirements, prepared technical documentation for Provider and Subscriber selection logic in the Facets Gateway process.
• Developed an ad-hoc directory to comply with mandated state provider directory regulations.
• Redesigned Amisys Medicaid and Medicare claim routing logic and workflow.
• Responsible for day to day support of Facets Gateway application and managing of the offshore programming team.
• Managed reverse data mapping (Facets to Amisys) for a Web Portal project and created stored procedures to extract Facets data. Interfaced with vendor and internal system units to in corporate new Facets reverse engineered file into current Web Portal file upload process, minimizing both vendor application re-coding and Affinity’s overall dependency on vendor support.

Software Engineer

Confidential, NJ

• Requirements gathering and analysis for development of the BizTalk Billing interfaces to Facets providing input data to the application.

Software Engineer

Confidential - NY

• As a team member, performed troubleshooting and triage of problems reported by domestic and international users of a complex billing system for a global financial services company. Supported day to day operations and implemented system enhancements. Developed and enhanced business logic for pricing increases and charging plans on SYBASE, Transact-SQL stored procedures and C++ on Microsoft Windows platform. Performed support for Bill Monitor and the interface for PeopleSoft Feed.

Software Engineer

Confidential, NJ

• Enhanced, maintained and tested GUI applications and backend C++ application for Billing, Subscriber/Member and Provider on Windows 2000 server environment using Visual Studio.NET. Used PVCS for source code control management. Designed and developed C++ batches to meet new and existing clients’ requirements.
• Managed database objects update from design phase through coding and unit testing for three TriZetto- supported DBMS: Oracle, Sybase and SQL Server 2000. Objects included database tables, triggers, complex stored procedures and conversion scripts. Responsible for providing a team of seven developers with guidance for application support and maintenance, including converted Runbooks and Procbooks from Perl script to XML during system migration from UNIX to Windows 2000 server.
• Managed performance and fine-tuning of complex stored procedures and conversion scripts, defined and established programming standards. Interfaced with users to define functional specifications. As a key member of the policy team, created Graphical User Interface Standards resulting in creation of production programming templates and screens for final delivery to clients.