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Sr. Healthcare Edi Lead Resume

Eden Prairie, MN

PROFESSIONAL SUMMARY:

  • Healthcare EDI Lead with over 10 years of experience.
  • Extensive experience with Medicaid Information Technology Architecture (MITA).
  • More than 4 years experience in public health policy and research with a focus on Medicaid, Medicaid managed care, Medicare Advantage, coverage and access issues at the federal and local level.
  • Excellent knowledge of Health Insurance Portability and Accountability Act HIPAA transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277 and ICD9 - ICD10
  • Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.
  • Good working knowledge of HIPAA ICD10 and HIPAA transaction requirements.
  • Excellent knowledge of HIPAA standards, EDI Electronic data interchange, transaction Syntax like ANSI X12
  • Rich experience of SDLC, Business Process Analysis, Business Process Management, Document Management Applications
  • Experienced in HIPAA Transaction Code Sets and non-HIPAA compliant interfaces.
  • Experienced with enterprise wide HIPAA Risk Assessment and Gap Analysis, the development of a comprehensive HIPAA compliance project plan, and the delivery of a recommendations report on the organizational approach and strategy for HIPAA compliance
  • Facilitated User Acceptance Testing (UAT) with the stakeholders and the business users as well as trained users to use the system configured.
  • Excellent skills in Business Modeling and Use Case Development using UML methodology.
  • Good time management and interpersonal skills, which helps in conducting project meetings, reviews, walkthroughs, and customer interviews according to the varied needs of the people involved.

TECHNICAL SKILLS:

Operating Systems: Windows 2000/XP/Vista/7, 8 UNIX, Linux

Languages: C, C++, Java

Web Technology/ Server: HTML, XML, HTTP

Methodologies: Rational Unified Process (RUP), Waterfall, Agile/Scrum SDLC

Business Tools: Rational Suite (Requisite Pro, Rose, Clear Case), UML, MS Visio

Software Packages: MS Office, MS Project, MS SharePoint, Dream Weaver, MS Visual Studio, Adobe Photoshop

Testing Tools: Rational Clear Quest, Mercury Test Director

Database: Oracle, SQL Server

PROFESSIONAL EXPERIENCE:

Sr. Healthcare EDI Lead

Confidential, Eden Prairie, MN

Responsibilities:

  • Involved in creating and modeling the AS IS diagrams and TO BE system and also accomplished the GAP Analysis.
  • Involved in improving the systems development and health care management for the Medicaid enterprise.
  • Define and document EDI business process requirements
  • Monitor the flow of data through EDI applications to ensure all operational systems are functioning properly when needed
  • Defined and clarified specifications for EDI software enhancements through communication with various departments
  • Break down of the services from the MMIS Logical Design into multiple layers of normalized functionality that correspond to utility services, general business services and Medicaid specific services.
  • Integrated Business and IT transformation across the enterprise to improve the administration of Medicaid program.
  • Recommend 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.

Environment: Healthcare, HIPAA, ICD-9, 10, Medicare, Medicaid, Medicaid Reporting, Claims Processing System, Claims, Adjudication, Benefits, EDI, MMIS, MITA, UML, Jira

Sr. Healthcare Business Analyst/EDI Specialist

Confidential, Portland, OR

Responsibilities:

  • Worked with Medicaid Management Information System (MMIS), Medicare or Health Insurance Claims Processing system.
  • Streamlined Claims 837 EDI X12 Migration project by gathering functional specifications in Edifecs
  • Analyzed Audit and Change Files of 834, 835, 820, 837 PDI HIPAA EDI Transactions using MS Word, MS Excel, MS Access and Facets PROD PPMO
  • Worked on gap analysis framework to identify AS-IS processes of claims transactions of HIPAA X 12 4010/4010 A standard and TO-BE processes (ICD-10-CM and ICD-10-PCS compliance requirements) of 5010 standard. Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
  • Developed detailed use case models and supporting specifications. Developed data flow diagrams to capture flow of information between systems.
  • Performed objective assessment of the SDLC processes and capabilities to effectively mitigate risk and test a Point-Of-Sale/Service enterprise application
  • Performed source to destination data mapping to migrate data from legacy system to new system.
  • Worked on EDI HIPAA 5010, EDI X12 formats transaction like (834, 835,837, 270, and 271).
  • Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
  • Worked a lot on MITA processes, MITA architecture framework and MITA guidelines.
  • Strong knowledge and experience in Healthcare industry.
  • Functional knowledge of Medicaid Management Information System (MMIS).
  • Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.
  • Worked with Over 25 Payers data (including Federal) gaining in-depth knowledge in claims processing by a Payer by trending the data based on ICD, CPT 4 Codes and Denial reversal.

Environment: Healthcare Insurance, Public Sector, BI Tools, EDI, Project Management, MS-Office, EDI, HIPAA, ICD-9, 10, Medicare, Medicaid, Medicaid Reporting, Claims Processing System, Claims, Adjudication, MMIS, MITA, SQL Server, Jira

Sr. Healthcare EDI Lead

Confidential, Salt Lake City, UT

Responsibilities:

  • Facilitated and participated in Joint Application Development session for requirements gathering, analysis and design that helped in determining the functional specifications, writing use cases and creating prototypes.
  • Developed seamless and integrated systems that effectively communicated and achieved common Medicaid goals.
  • Worked a lot on MITA processes, MITA architecture framework and MITA guidelines.
  • Strong knowledge and experience in Healthcare industry. Functional knowledge of Medicaid Management Information System (MMIS).
  • Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.
  • Implementing policies, procedures and controls developed in collaboration with the HIPAA
  • Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensure that critical requirements are not missed.
  • Ability to quickly understand and interpret data models and data flows.
  • Worked with the client architecture team in defining tools, processes and technologies to be leveraged on the data warehouse.
  • Participated in various meetings and discussed Enhancement and Modification Request issues.
  • Involved in data review, data mapping and data validation using SQL queries.
  • Involved in gathering Business Requirements, interacted with the Users, Design and Development teams, Project Manager and Subject Matter Experts (SMEs) to get a better understanding of the Business Processes.

Environment: Healthcare Insurance, EDI, MS-Office Suite, MS SharePoint, MS Visio, EDI, HIPAA, ICD-9, 10, Medicare, Medicaid, MMIS, MITA, Claims Processing System, Oracle, EPIC, MS project, MS SQL Server, SOW&PMO, UML

Healthcare Business Analyst/EDI Consultant

Confidential, Tempe, AZ

Responsibilities:

  • Mapped the current business process, gathered business requirements and wrote in Business Requirement Document.
  • Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
  • Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.
  • Facilitated Joint Application Development (JAD) sessions to identify business rules and requirements and then documented them in a format that can be reviewed and understood by both business people and technical people.
  • Worked with developers to gather information for a set of Service Development Plan templates documenting the service’s requirements, functional, and technical design. Included SDLC documentation and ITIL-based checklists.
  • Participated in walkthroughs and review meetings with Business Analysts & Development team.
  • Demonstrate an expertise in EHCM business processes and systems.
  • Involved in SOW Process as a part of team
  • Documented, edited, proofread various reports required during the software development and prepared the presentations during the various design reviews with the Assessors.

Environment: Healthcare Insurance, Windows XP, MS-Office Suite, MS Visio, MS SharePoint, Healthcare, EDI, HIPAA, ICD-9, 10, BI Tools, Medicare, Medicaid, MMIS, MITA, Claims Processing System, Oracle, ASP, XML, EDI, MS-Project, Portico Database.

Healthcare Business Analyst

Confidential, Indianapolis, IN

Responsibilities:

  • Responsible to track, document, capture, manage and communicate the requirements using Rational Requisite Pro which helped in controlling numerous artifacts produced by the teams who are working on same project, by keeping track of - simultaneous update, change notification, multiple versions.
  • Implemented RUP iterative approach, which allowed increasing the understanding of the problem through successive refinements, helped to incrementally grow an effective solution over multiple iterations.
  • Used RUP with most of its supporting tools, which automate large parts of the process that are used to create and maintain the various artifacts such as visual modeling using UML through Rational Rose.
  • Analyzed the problem domain, specified features, established baseline architecture, developed the project plan, and risk analysis.
  • Translate high-level business requirements into functional/system requirements for the EHCM organization and manage changes to such specifications.

Environment: MS-Project, MS-Office Suite, MS Visio, MS SharePoint, Healthcare, EDI, HIPAA, ICD-9, 10, Test Directors, Portico Database .

Business Analyst

Confidential

Responsibilities:

  • Worked as a Business Analyst to review the project plan and formulated schedule to gather requirements from business users
  • Designed use-cases and use-case models to further refine the requirements and understand the business processes. Worked extensively in Rational Requisite Pro to organize and catalog requirements, documents, and use-case documents.
  • Interacted with Traders, Developers, Project Manager and Process Analysts to understand the business processes, identified enhancements and gathered business requirements.
  • Prepared Business Requirements Document (BRD)
  • Created UML diagrams such as Use Case Diagrams, Activity Diagrams, Data-Flow Diagrams using Rational Rose and MS Visio to define the Business Process and Data Process model
  • Conducted JAD sessions to discuss requirements and resolve conflicts between stakeholders

Environment: Rational Requisite Pro, Rational Unified Process (RUP), Windows XP/2000, UML, MS-Project, MS-Office Suite, MS Visio.

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