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Senior Manager Resume

SUMMARY:

  • Over 13 years of IT experience in Health Care in the areas of Process Migration and Transition, Business Analysis and Development, and Process Management in the field of Healthcare - Medical Billing and Collection, EDI Transactions, Workers Compensation, Life Insurance, and Telecom Industry.
  • Strong knowledge of the Software Development Life Cycle methodologies, mainly in Agile and Waterfall models.
  • As an Agile Scrum Master:
  • Have prepared and prioritized the Product and Sprint backlogs.
  • Facilitating Daily scrum meetings, sprint planning, sprint review, and sprint retrospective
  • Channelize requirements and discuss requirements and stories with the development team.
  • Being adept in conflict management and conflict resolution.
  • Gather data and provide Agile metrics
  • Plan releases and manage client deliverables.
  • Working with Product owner on artifacts such as product backlog, sprint backlog, sprint burndown, release burndown.
  • Facilitating Scrum meetings for offshore Scrum teams in US and India.
  • Managing the overall performance and delivery of cross-functional
  • Facilitating sprint planning as Scrum master for multiple Scrum teams;
  • Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound Claims 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
  • Experienced in converting custom flat file data like legacy NSF, EZ-Cap and NON-Standard data into ANSI 837 format by mapping the fields from flat file values into 837 segment and element values.
  • Work Knowledge of Citrix Mainframe (IBM) AS400C, AS400P, Ovation systems, Soarian Enterprise Revenue Cycle Management - Siemens Healthcare, Clear Case Web-Configuration Management, CHARMNT- Defect Tracking System, Merlin - Requirement Data Management system, MNeConnect provider portal and TransUnion MedConnect™ payer-provider portal.
  • To create basic SQL queries to perform analysis of the data in the databases and ad-hoc reports.
  • Code knowledge of HCPCS, CPT, ICD-9 CM Procedure and Diagnosis codes; J-codes pricing, fee schedule, NDC codes and claim adjudication life cycle.
  • Experience in Conversion of HIPAA X12 4010 version format to X12 5010 version format and ICD-9 codes to ICD-10 codes.
  • Extensive knowledge of Medicaid and Medicare health plans.
  • Expertise in client interactions and business requirements gathering.
  • Experienced in interacting with business users in identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD), Detailed Design documents and Software Requirement Specification (SRS) across the deliverables of a project.
  • Expertise in analyzing existing systems and procedures and facilitate effective decision-making to the management
  • Preparing feasibility study report, core team onsite analysis plan, process mapping, preparing process manuals, training documents
  • Experienced in facilitating Joint Application Development (JAD), Rapid Application Development (RAD) and Joint Requirement Planning (JRP) sessions, interviews, workshops and requirement elicitation sessions with end-users, clients, stakeholders and development team.
  • Experienced in analyzing and documenting business requirements and system functional specifications including Use Cases
  • Proficient in creating Sequence Diagrams, Collaboration diagrams, Activity Diagrams, Class Diagrams and process flow diagrams using Microsoft Visio
  • Experienced in handling Change Management and strong knowledge of Business Process Modeling, Business Intelligence and Business Architecture.
  • Professional with extensive experience in the development, implementation and integration of strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills.
  • Reviewing of Test Plans and suggesting additional cases or modifying the existing cases.
  • Skilled in validation and testing complex scenarios for the maintenance of quality standards in projects
  • Creative person capable of forming and maintaining positive and productive team environments with integrative thinking skills.
  • Exceptional Problem Solving and Sound Decision Making capabilities, along with the ability to resolve difficult situations.
  • Excellent interpersonal, communication and organizational skills with proven abilities in team management and client relationship management

PROFESSIONAL EXPERIENCE:

Confidential

Senior Manager

  • Involved in analyzing and understanding the Client Requirements and act as the liaison between the business area and the systems team
  • Was a part of four member team on-shore for migrating the legacy encounter processing system into new web based platform.
  • Managing a team of developers, analyst and testers in implementing the project, involved in POC
  • Requirements discussions with business units, gathering business requirements, ensuring all business requirements were satisfactorily met.
  • Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, Implementation and testing for processing of claim files and editing and exporting to health plans.
  • Analyzed, coordinated, documented and managed project requirements, project processes and procedures and its changes throughout the software development lifecycle.
  • Responsible for leading JAD sessions with SME's from the client side and Interviewed DBA's.
  • Carried out detailed analysis on ANSI 837, 997, 835, 270, and 271 transactions.
  • Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, Implementation and testing for processing of claims.
  • Analyzed, coordinated, documented and managed project requirements, project processes and procedures and its changes throughout the software development lifecycle.
  • Created and used SQL queries to do analysis of the data in the claims databases.
  • Work closely with technical resources, systems analysts and business analysts for root cause analysis of complex system problems.
  • Created and updated data mapping documents with reference to the source for 270/271, 276/277 and 837.
  • Converted custom flat file data like legacy NSF, EZ-Cap and NON-Standard data into ANSI 837 format by mapping the fields from flat file values into X12 837 formats.
  • Conducted GAP analysis by understanding the AS- IS system and the TO-BE system requirements by having discussions with the SME’s.
  • Accounted for and anticipated impacts to enterprise services with respect to the transition from HIPAA 4010 to 5010. More specifically, impacts related to the support of the following HIPAA Transactions: 837, 835, 270/271 and 276/277.
  • Responsible for tracking all requirements CR’s in the sprint sheet.
  • Effortlessly performed as a liaison between the management and the development team for requirements and Quality Analysis
  • Helped design, communicated, and enhanced QA/testing plans for the Application
  • Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 and CPT codes.
  • Created documents like the BRD/FSD with detailed understanding, handled walkthrough sessions with development, architect as well as QA
  • Develop and maintain user manuals and guidelines.
  • Train end users to operate new or modified programs.
  • Arranges project requirements in programming sequence by analyzing requirements; preparing workflow charts and diagram using knowledge of computer capabilities, subject matter, programming language, and logic.
  • Analyze, review and alter program to increase operating efficiency or adapt to new requirements.
  • Train users to use program and provide technical assistance to end users.

Assistant Manage

Confidential

  • IGI ORBIT® implementation for the Minnesota State health council to fulfill their E3 solution. The solution consists of DDE Solution for 837I, 837P; 837D EDI Formats.
  • Involved in all stages of the project from its requirement gathering, analyzing requirement to deployment stage.
  • Gathering payer business requirements from the health plans and converting them as functional requirements.
  • Creating payer implementation and on-boarding documents and manuals.
  • Engaged in the process of health plan implementation for 837I, 837P, 837D, 835, 270/271 and 276/277 EDI transactions.
  • Understanding the customer needs and gathering requirements from customers for batch claims file implementation development.
  • Carried out detailed analysis on ANSI 837,997,835, 270, and 271 transactions.
  • Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, Implementation and testing for processing of claims.
  • Analyzed, coordinated, documented and managed project requirements, project processes and procedures and its changes throughout the software development lifecycle.
  • Responsible for leading JAD sessions with SME's from the client side and Interviewed DBA's.
  • Carried out detailed analysis on ANSI 837,997,835, 270, and 271 transactions.
  • Created and used SQL queries to do analysis of the data in the claims databases.
  • Work closely with technical resources, systems analysts and business analysts for root cause analysis of complex system problems.
  • Created and updated data mapping documents with reference to the source for 270/271, 276/277 and 837.
  • Initializing the testing process, analyzing the batch files for new customers and moving them to live
  • Analyzing the live claims batch files and giving the feedback to customers if any.
  • Interacting with customers whenever there are issues with the batch files.
  • Handling Medicare and Medicaid provider enrollment documents
  • Handling exsiccations from customers and payers.
  • Conducting continuous audits to ensure compliance and sound functioning of the process and the teams adheres to all the quality tools and procedures.
  • Developed the Work instructions, Workflows & Process flows (VISIO) for GAP Analysis, Payer Tracking, Analyzing the business needs of the clients.

Confidential

Business analyst

  • 24/7 Customer service helpdesk implantation for handling queries like technical, connectivity and application issues from various hospitals (sites) and research centers via Inbound calls, Outbound calls, Voice mail and E-mail.
  • Involved in all stages of the project from its requirement gathering to deployment stage and involved in analyzing requirements.
  • Prepare Roster for 24/7 shift schedules.

Confidential

Business analyst

  • Gather Business needs of the clients and perform gap analysis against Implementation Guide EDI 837I, 837P, 837D.
  • Gather national and payer specific claim requirements from payer companion guides, billing manuals, etc. and record them in a common data repository developed by the organization-MERLIN
  • Act as the liaison between the business area and the systems team; work closely with other team members, including technical leads from other IT teams in preparing new releases and application enhancements.
  • Responsible for creating business requirements and developing QA test plans.
  • Review and analysis of various existing documents and facilitation of process walk-throughs and validations.
  • Coordinate and facilitate, in liaison with leaders, informal and formal meetings to share experiences and develop new knowledge.
  • Business process mapping; map business processes per established standards, using a defined toolset.
  • Document standards, best practices, methodologies, policies and procedures, for both the business community as well as the IT Department.
  • Learning support: Provide content development expertise for the development of structured learning products. Prior experience in US Healthcare and educational background help perform as SME/Domain Consultant.
  • Gather and interpret billing and business requirements for Institutional and Professional claims, both paper and electronic; Review of Interpretation of business scenarios and conducting various testing to ensure the quality of each rule.
  • Developed Process flows, using MS VISIO, for Gap Analysis of Business requirements.
  • Expertise in analyzing the CMS transmittals, Claredi report interpretation and Parity Testing analysis

Confidential

Senior Customer Service Representative

  • Was a part of three member team on-shore for migrating the Life Insurance and the Debt Collection projects from the state of Illinois and Ohio respectively.
  • Involved in analyzing and understanding the Client Requirements and act as the liaison between the business area and the systems team
  • Process Mapping of As IS and To Be - Process Context Diagram, High Level Process Flow, Swim lane Process Flows.
  • Preparation of Process Manuals - SIPOC, FD-IPO, Key Stroke Documents
  • Preparing Feasibility study Repot, Core Team Onsite Analysis Plan, Core Team Onsite Analysis Report, Training Documents, QC Process - (Setting up Quality Parameters & Preparing reports), Resource Recruitment plan, Process Training and Process Initiation.

Confidential

Claims Examiner/Adjudication

  • Certified Workers’ Compensation Claims Examiner
  • Involved in making Three Point Contact - injured employee, employer and the treating physician within 24 hours after the knowledge of the injury.
  • Involved in analyzing, interpreting and determining the compensability of the claim, which involves; Coverage Issues, Investigation, Evaluation, Medical Management, Litigation Management, Negotiation and Recovery/Subrogation
  • Involved in the process for payment of Expense and Medical bills for providers and vendors and the Disability Benefit payments for the claimant by working simultaneously in various applications
  • Coverage Issues-checking whether the policy is in force, checking for Concurrent Coverage, Wrap-Up coverage & other relevant issues.
  • Investigation-Relevant information has to be obtained to determine compensability & exposure, capturing relevant information from Employee, Employer & doctor. Potential fraud indicators should be recognized & investigated.
  • Evaluation-Set reserves appropriately & adjust it over the life of the claim. For reserves needs to recognize & understand the Probable Ultimate Cost (PUC) of the claim to guide the client in his claims’ money management.
  • Medical & Disability Management- effectively direct the claimant to the panel of Medical Providers’ Network (MPN). Use effectively Telephonic Case Managers (TCM), Field Case Managers (FCM), Independent Medical Examiners (IME), analyze relevant medical records, medical bills reviewed as per Fee Schedule audited & re-priced medical bills paid timely.
  • Litigation Management-Appropriate Litigation plan & budget developed.
  • Negotiation-Often in disputes, CE needs to settle the case with intense negotiation that involves discussion with clients, defense attorney, and Plaintiff attorney & need to comply with lot of legal requirements.
  • Recovery/Subrogation-To check for if there are any Subrogation Potential (Third Party Liability)
  • Involved in the process of payment of Expense and Medical bills for providers, vendors and the claimant working simultaneously in various software applications and also contacting the Medical Providers as well as the attorneys for the payment of the outstanding bills.
  • Worked on Citrix Mainframe (IBM) AS400C, AS400P and Ovation systems

Confidential

Claims Examiner

  • Claim processing for health insurance claims for a third party administrator in US.
  • Filing claims to the Insurance company and analyzing the denied and disputed claims
  • Interaction with Patients and Insurance representatives for various billing issues for the claims to be processed and handled escalated calls of the agents.
  • Training the new recruits & regular members on Accounts Receivable Analysis and patient calling.; Conducted Accent Neutralization and Americanism training as a refreshing course
  • Preparation of Reports & Team summary information & presenting the same to the Management to increase the production & productivity of the Team.

Confidential

Customer Service Executive

  • Aware of American Telecom policies and billing procedures, have interacted with the Agents of the top most Telecom companies in the US regarding trouble shooting of various highly specific telecom issues; Involved in providing customer service, attending service issues and billing queries; Interaction with customers & handling their queries & also cross selling & up selling on the same call and handling escalated calls.

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