SUMMARY:

• EDI Systems/Data Analyst, experienced working in fast paced environments demanding strong organizational, technical and interpersonal skills.
• Detail - oriented and resourceful in completing projects: able to multi-task effectively.
• Implemented Confidential products including Ramp Manager & Transaction Manager
• Designed and tested programs in Ramp as per business requirement for all HIPAA transactions
• Compared 4010 / 5010 analysis and recorded changes in excel grid.
• Proficient with commercial and government health insurance plans.
• Methodologies: SDLC (Waterfall Method, Agile Methodology). Completed a two-day workshop Sponsored by Confidential .
• Certified Advance Scrum Master. Completed and pass a two-day training of Scrum Master provided by Scaled Agile Framework.
• HIPAA Tools: Claredi, Confidential SpecBuilder, MapBuilder, & Transaction Management
• Develop an 835-map using Confidential MapBuilder to convert positional flat file into X12 HIPPA compliant format using Java Script.
• Complete knowledge of “MHS” Healthcare System
• Use agile systems and strategies to provide quick and feasible solutions, based on agile system, to the organization
• Designed “Ramp Manager” using agile methodology to a group of trading partners based on iterative development and presented tutorials on using agile development techniques to trading partners and billing agencies and software vendors.
• Directed the skills enhancement efforts of Business System Analysts, Designers and Developers to adopt processes based on Agile/Scrum development techniques. Introduced techniques such as Domain Modeling, Executable Requirements, Test Driven Development and Continuous Integration for SIT and UAT testing.
• Successfully completed an 80 hours’ crash course for SQL Server Developer/T-SQL Programming.

TECHNICAL SKILLS:

• Java Scripting
• C++ programming
• Data mining & modeling
• Decision Support System & Data Analytics
• Business Data Visualization
• Software Engineering/Object Oriented Programming
• PL/SQL
• VB.Net
• Statistical Computing
• Systems Analysis & Integration
• Requirement Analysis & System Design
• Mainframe COBOL
• Information Security
• Healthcare Information Technology and Management Systems
• B.S (Accounting & Management)
• University Of Karachi, Pakistan
• SQL Server 2012: T-SQL Programming & Performance Tuning
• Successfully complete an 80 hours’ refresher crash course for SQL Database Programming

WORK HISTORY:

EDI Data Analyst/Systems Analyst

Confidential, New York, NY

Responsibilities:

• Completed Confidential EDI Confidential Integrator training to define data mapping rule, setting up FTP connections and trading partner profiles to align all the X12 transaction sets.
• Developed EDI maps using the Windows Confidential tool
• Implemented EDI maps for transactions 820, 834, 837, 835, 270 and generated functional acknowledgment 999 using the X12 standard, in versions ranging from 4010 through 5010
• Created maps for both inbound and outbound trading partner relationships
• Performed system wide testing on all EDI transactions and configuration of all trading partners
• Ensured the correct translation was generated by Confidential, and that the files were accepted correctly into the ERP application
• Performed all EDI Coordinator tasks that include analyzing internal business needs as well as external trading partner needs, requirements and requests as they relate to EDI 820 Premium Payment and 834 Benefit Enrollment and Maintenance
• Designed, coded, and implemented SAS code for analytic studies to fulfill internal and external client requests, maintained, evaluated, and reported on recurring analytic studies. Perform data hygiene and created data validation program
• Facilitated EDI testing with trading partners to implement new initiatives, transaction sets, version upgrades and alterations to current transaction sets
• Wrote SQL queries to evaluate and update inbound data. Create SQL processing script for new data sets.
• Developed and distributed documentation of EDI specifications, information and procedures as they related to the business issuing formal announcements, notifications or acknowledgments pertinent to upgrades, trading partners, fixes changes, and enhancements etc.
• Write complex SQL queries to evaluate and update inbound data. Create SQL processing script templates for new datasets. This consists of new written workaround scripts if needed to verify raw data
• Review and correct SQL statements, create stored procedures as needed for data processing and new data sets
• Use SQL queries to identify and analyze data anomalies.
• Experience with data quality control, data manipulation and electronic health records
• Maintained HIPPA Compliance while conducting business with vendors, clients, and members

Data Analyst-Oracle-SQL Development/Systems Analyst

Confidential, Pittsburgh, PA

Responsibilities:

• Confidential is a Medicare/Medicaid health insurance provider based in Pittsburgh, PA. It provides managed care services for government sponsored health care programs focusing on Medicare and Medicaid. It offers a variety of health insurance products to our members, including Medicare Advantage plan in Mid Atlantic region, e.g. Ohio, Kentucky, Tennessee, West Virginia, North Carolina and Delaware.
• Coordinated Healthcare Effectiveness Data and Information Set (HEDIS) project from planning to selecting measures and submission to the National Committee for Quality Assurance (NCQA).
• Research and analyze software solutions to meet requirements for case management, predictive modeling, NCQA HEDIS reporting and provider profiling.
• Testing on both Oracle/PL SQL and Microsoft SQL Server (MS-SQL) platforms.
• Business analyst and Data analyst for yearly NCQA HEDIS audit and NCQA MCO accreditation process.
• Involved in the creation and maintenance of 270/271 work flows plan and artifacts.
• Actively took part in validating and certifying the 270 transactions with Confidential Ramp Management application and did troubleshooting and tweaking the . Confidential files.
• Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level.
• Analyzed HIPAA 5010 related to 270/271, 834, 835, and 837 transactions and performed gap analysis between state mandated companion guides and current business edits.
• Responsible for designing future state processes for HIPAA 5010 transaction processing EDI 837 and 835, as well Provider, Member, and Lab files.
• Wrote clear concise detailed Systems Requirements Specifications (SRS) documents and user documentation in accordance to guidelines and standards of a level where developers can interpret, design and develop the application with minimum guidance.

Developer/Systems Analyst

Confidential, Pittsburgh, PA

Responsibilities:

• Define mapping specification and requirement in Confidential MapBuilder.
• Proficient in JavaScript and have used these skills in Confidential MapBuilder.
• Created detailed requirements from a Developer perspective, prepared the guideline using . Confidential files to convert positional flat file into X12 HIPAA Compliant format.
• Completed an end-to-end map for a major dental payer into 835 format for the state of NY.
• Completed and tested an 835 ERA from a positional flat file using Confidential MapBuilder by creating multiple test scenarios.
• Expertise with the following Confidential tools:
• Experience configuring Confidential (and creating maps) for translating and validating HIPAA 5010 transactions and customized transaction formats as per client specifications by using various functions and logics within Confidential MapBuilder to successfully build the Map to translate the flat/Non X12 file into HIPAA compliant format .
• Configure the Confidential and all the channels. Creating a new interchange. Update the interchange name. Update sender or receiver ID’s. Update trading partner name at interchange level. Update the Confidential (Error Severity File) severity configuration at interchange level. Update the Confidential (file path) at transaction level. Create lookup property for Payer ID in Selector.

Sr. EDI Business/Systems Analyst

Confidential, Pittsburgh, PA

Responsibilities:

• Good understanding of tuning T-SQL (DML, DDL) in SQL Server 2012
• Developed and prepared requirements tractability matrix to be used in software development and QA testing.
• Knowledge of creating Tables, Stored Procedures, Views, Indexes, Trigger, User Defined Functions, and Data Integrity in observing business rules.
• Identified required information fields and developed data dictionary and data mapping.
• Wrote SQL scripts for creating performance evaluation reports.
• Tested, accepted testing and implementation of information systems, modules and subsystems.
• Ability to design, build, and implement business solutions
• Experience in writing SQL queries/scripts for data analysis and QA report testing
• Experience in working with QA testing teams, while interacting with business users and gathering user’s requirements to develop necessary test plans, and test cases
• Extensive experience in gathering Business and Functional Requirements, developing Use Cases, conducting Gap
• Writing and reading data objects i.e. Stored Procedures and Tables in SQL Server
• Working closely with behavioral healthcare agencies and state wide reporting system
• Writing standard SQL queries and optimizing SQL queries
• Co-authored Business Requirements Specification (BRS), Use Case Specifications, Systems Requirement Specification (SRS) and Change Request along with the Business Group and the IT project group members

Sr. EDI Business Analyst

Confidential, Annapolis, MD

Responsibilities:

• Lead operational activity for data acquisition, quality management and integration from disparate sources for more than 100 health plans in compliance with HIPAA regulation
• Define and execute product strategy for Business Intelligence (BI) platform to develop reporting solutions for retrospective and prospective risk adjustment, claims and payments integrity, clinical and quality outcomes measurement for HEDIS.
• Data Analytics: Ability to assimilate large data sets by constructing optimal data models to derive relevant insights for resolution of a business problems.
• Program Management: Establish and track cross functional programs such as data governance by obtaining sponsorship and participation of stakeholder including executive leadership.
• Using SQL queries & stored procedures to perform data analytics on incoming test and production files.
• Good knowledge of Business Analysis methodologies, Iterative and Incremental Software Development Life Cycle (SDLC) using MS-VISIO.
• Proficient in gathering business and technical requirements from both formal and informal sessions through interviews, NetMeeting, questionnaire, video conferencing, and conference calls .
• Developed a user guide for data check process for non X12 files like Provider, Encounter, Pharmacy, Member, Enrollment, and Laboratory.
• Perform data check for reporting purposes for all inbound X12 files.
• Maintain data integrity by using SQL Server Management Studio 2008 R2.
• Experience with SQL and data conversions, Data mapping and data validation.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI
• Identified all necessary Business and System Use Cases from requirements, created UML diagrams including Use Case Diagrams, Activity Diagrams, and Sequence Diagrams using Microsoft Visio

Sr. EDI Business Analyst

Confidential, Southborough, MA

Responsibilities:

• Conducted and performed analysis of Confidential for 837 claim submission to CMS, document and produced test files and involved in validating Confidential files via Confidential .
• Experience in developing Use case diagrams, Business flow diagrams, Activity and Sequence diagrams using tools like MS Visio.
• For Confidential - Design and document data process for all adjudicated claims to be submitted.
• Develop test cases to monitor the submission frequency of Encounter Data.
• Design EDI Dashboard for encounter data to identify and report errors in terms of graphical representation for accepted and rejected claims.
• Work with Trading Partners and clients to facilitate error correction and identify process improvement opportunities to improve accuracy and reporting statistical metrics.
• Work with CMS, provider network, claim and IT teams to identify errors and correct Encounter errors.
• Prepare and validate Encounter Data accuracy via Confidential and BizTalk.
• Adept at preparing Business Requirement Documents (BRD), defining project scope/plans, Technical Requirements Specifications (TSD), Functional Specification Documents (FSD), Systems Requirements Specifications (SRS) and delivering project/status reports
• Gathered requirements from the clients and developed crosswalks for 277/288, 834, 835, 837 P/I claims.

EDI Business Analyst

Confidential, Pittsburgh, PA

Responsibilities:

• The main deliverable of this assignment as to facilitate Business Analyst in transitioning of HIPAA version change from 4010 to 5010 for ANSI X12 transactions.
• Worked on data mapping of 837 transactions (I, P & D), 270/271 (Eligibility and Response), 276/277 (Claim Status Request and Response), 834 (Benefit Enrollment and Maintenance).
• Involved in discussion with subject matter experts during gap analysis sessions to identify the areas of impact to CIGNA.
• Created 999 5010 implementation level acknowledgements.
• Worked with EDI Team for Data Mapping and Building maps for 270, 276, and 837 using .XSD files.
• Worked in close collaboration with the Project Manager and business users to gather, analyze and document the functional requirements for the projects.
• Assisted in the writing of Confidential specific 5010 Implementation and Errata guide for all ANSI X12 transactions.

EDI Business Analyst

Confidential, Pittsburgh, PA

Responsibilities:

• Gap Analysis: Review 4010A1 and 5010 Implementation Guides, Addendum and Erratas to define gaps in Loops, Segments, Elements, Composites Business Rules, Qualifier and Code Sets. Document each gap item for further Impact Analysis.
• Impact Assessment- Transactions: Use Confidential Implementation Guide and Confidential Gap Analysis documents to assist in Impact documentation. Stake holder interviews, Companion Guide analysis, Vendor Meeting (Apria Health) and IT staff input to determine critical Impact Issues.
• 5010 Requirements: Assessment documentation, including Gap and Impact details were prepared, specifically for the initial framework of 5010 Requirements. Having documented impacted areas, in terms of a road map, for 5010 Requirements completion processes.
• Develop and certify test cases for 5010 compliancy for all HIPAA transactions (i.e. 835, 270/271, 276/277 and 837 P and I) in Confidential .
• Actively involved in coordinating the Confidential programming application activities.
• Analyze, design, implement and define PNC business guidelines in Confidential SpecBuilder.
• Develop PNC business rules and prepare Auto Fixes rules and set the . Confidential files for successful claim validation in Confidential .
• Design and develop HCA (Health Care Application) for DDE Claim (Direct Data Entry). First this system is used as an Online Claim Submission by directly entering the claims. The second use is to correct the rejected claims online for an affordable desktop solution for Providers.
• Develop Project Management Documents. Perform As-Is and To-Be gap analysis. Work with Providers and Clearing Houses to review and modify requests and updates BUR document and Functional Design Documentation.
• Involved in re-engineering of the EDI Gateway to assist in the development of HIPAA repository to process 5010 claims.
• Performed validation of test scenarios in Confidential SpecBuilder and rectify the errors based on the . Confidential file guidelines and HIPAA mandated rules to ensure the smooth claim processing.
• Provide technical and procedural support for “User Acceptance Testing” (UAT) and “Systems Integration Testing” (SIT).

EDI Business Analyst

Confidential, Quincy, MA

Responsibilities:

• Confidential is a non-profit health care insurance company aimed at providing affordable and quality healthcare to its subscribers. The implementation of “Ramp Manager” is to transition the prevailing health care process into an optimized health care process known as “EDI Transaction Management”. The purpose of implementing “Ramp Manager” in 837 transactions is to reduce costs, avoid redundancy in claim processing and giving the flexibility to the Trading Partners to test their own 837 files before submitting the live production files.
• Constructed the Business Requirement Document and the Technical Requirement Document for 837 Professional and Institutional claims (Inbound), 835 (Outbound), 270/271 (Eligibility Request and Response), 276 (Claim Status Request), 277ACK (Healthcare Claim Acknowledgment).
• Perform system testing on all EDI transactions both inbound and outbound.
• Setting up new trading partners and maintain existing TPA in submitter profile.
• Coordinating with the providers and hospitals to analyze requirements for NPI guidelines.
• Built automated testing routines for the EDI system for NEHEN gateway, SFTP and FTP.
• Perform Analysis, Design, Development and Implementation of X12 EDI maps by using Ramp Manager Application (an Confidential Program).
• Working on the complete end-to-end processing of the 837 claims testing also helping debug and recommend change in Confidential guidelines for 837 claims processing in Ramp Manager.
• Responsible for testing and production processing and daily support for the 837 HIPAA transactions.
• Responsible for testing NPI dual submission files thru Claredi.
• Resolve support issues on claims submitted by providers and or other third parties submitting claims on provider’s behalf.
• Facilitate the business requirements and HIPAA edits.
• Provide technical support for 837 electronic claim submission and 835 ERA’S.
• Working closely with E-Business department to set up providers for EDI transactions.
• Actively involve with major Clearing Houses to support their EDI transactions.

Medical Billing/EDI Coordinator

Confidential, Dedham, MA

Responsibilities:

• Worked closely with Confidential and Medicaid to solve unpaid claims.
• Primarily responsible for submitting claims electronically.
• Recommending write offs for unpaid claims after a complete research.
• Rebill/Resubmit claims on paper (HCFA-1500, Med-9 & UB92)
• Responsible for submitting claims electronically to Confidential & Medicaid.
• Maintain the accuracy of claims through EDI X12 engine.
• Created Pre-Billing files for Confidential, Medicaid & Medicaid E-I.
• Submit the Pre-Billing files for Claredi test / HIPAA compliancy.
• Responsible for Live Billing files once Claredi test is completed.
• Posting of Cash payment electronically for Accounts Receivable.
• Process Confidential payments, print Confidential exception reports & applying payments.
• Update database and maintain Payment Tracking Forms for accuracy of payments.

Medical Billing Coordinator/Specialist

Confidential, Dedham, MA

Responsibilities:

• Primarily responsible for interpreting Confidential and CPT coding of incoming referrals, third party medical billing including urgent inpatient and outpatient admissions notifications. Prior authorization of referrals through internet, fax and Interactive Voice Response System (IVR).
• Design and institute automatic referral and direct authorization programs that accelerated patient referrals from weeks to days.
• Establish liaison role with claims and information system staff, to increase claim accuracy and improve direct electronic link with the provider sites for smooth flow of payments.
• Enter accounts for different insurances and their respective carriers i.e.:

Confidential

Responsibilities:

• This relates to identify and process claims according to insurance and authorization verification to their respective carriers. Review claims for accuracy and completed documentation, diagnosis billing codes and matching dollar amount.
• Validate all claims after their electronically submission to cleaning house. Work on denials of claims fix and rebill them on priority basis to maintain the cash flow.
• Enter all payments from Confidential ’s (Explanation Of Benefit) into Ntierprise system and post them electronically for Accounts Receivable balance.
• Prepare bad debt and revenue adjustment in accordance with established guidelines.
• Analyze and collect outstanding A/R balances.

Medical Specialty Assistant

Confidential, New Bedford, MA

Responsibilities:

• Worked as a cross-functional team player to act as a technical resource for other departments with reporting to Medical data-management department.
• Responsible for posting data and diagnosis codes into a database which I designed in MS-Access using VBA application for the easy access of necessary data.
• Maintain scheduling and patients appointments in Ntierprise system.
• Prepare and maintain different reports: