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Edi Claims Analyst Resume

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SUMMARY

  • Extensive noledge of Health IT systems used in Health Insurance and Pharmaceutical industries.
  • Extensive noledge of HIPAA, HIE, EMR, and EHR and Epic System
  • Proven aptitude to work independently while managing multiple tasks and deadlines in a highly complex, fast paced environment
  • Capable of writing basic SAS and SQL queries for data extraction and data mapping purpose.
  • Extensive working experience of all 7 phases of the software development life cycle (SDLC)

TECHNICAL SKILLS

Software Development: SDLC, Waterfall, & Agile

Database: Oracle SQL server Management Studio

Modeling and Designing tool: UML, Use case, Dataflow Diagram, Activity, Class, Sequence and Activity diagrams

Data Analysis Tool: MS visual Studio, MS Access & FlexSim 7

Office Tool: MS Word, MS Excel, MS PowerPoint, Outlook, SharePoint, & MS Visio

PROFESSIONAL EXPERIENCE

Confidential

EDI Claims Analyst

Responsibilities:

  • Generate and analyze data from various sources such as claims databases, Harvard Pilgrim internal health plan data, members, NPI Identifier system, electronic health record, and health Information Exchange Network data.
  • Also tracked the transmissions, drilled down on business data such as claims and enrollments, file support issues, and troubleshoot problems.
  • Extensive noledge of industry standard coding such as ICD - 9 and ICD-10 diagnosis and procedure codes, CPT/HCPCS codes, revenue codes, modifiers, Tax Id #, NPI system for billing and service provider and EDI clearinghouse processes.
  • Review, research and interpret claims data of 837 me and P- (Hospital and Medical claims)
  • Tracked both real-time and batch transactions of electronically transmitted paper claims (EDI Claims) to trading partners through Edifecs system and Filenet.
  • Varied working experience in enrollment, Summary of benefits, cost share, billing systems and claim submission requirements.

Confidential

Data Analyst

Responsibilities:

  • Formed different reports and performed data extraction for Axiom SL applications and Q-14 reporting.
  • Performed tasks under role as a finance- Dodd-Frank Regulatory Reporting Automation developer in production support team.
  • Created branches, data load, Workflow execution and L1 Reconciliation execution for different loan systems in DEV-SIT-BAT-PAT and PROD environments.
  • Maintained and Implemented Tracker files, Trend analysis report files, execution checklists and Production support macro level overview on SharePoint.

Confidential

Data Analyst

Responsibilities:

  • Created and analyzed data using SQL server Management Studio to provide Ad-hoc reports and basic stored procedure and queries in SAPPHIRE\REPORT, RPTDEV3 and MODELT01 servers in SQL Studio.
  • Acquired data report request from Claim, enrollment, billing, and provider data sources and maintained databases in Facets, Data ware house, Production, Model Office and Development environment.
  • Identified, evaluated and provided data results and set the criteria of Procedure codes, encounter type and as of demand in data request by end users.
  • Created Crystal reports and Claim adjustment Project- Alexsys team application for BMCHP.
  • Has a working noledge of Facets Data dictionary, schema, and provider databases.

Confidential

Business Systems Analyst

Responsibilities:

  • Worked with QNXT- TriZetto systems- Providers, Sponsors, Members, A/R account and Premium Billing
  • Comprehensively ran testing processes and defect management tool such as HP Quality Center.
  • Gathered, analyzed and reviewed requirements for Business Requirement Document (BRD), Ops Docs and Functional Required Documents.
  • Developed and worked on test cases, test scenarios, workflows, use case scenarios, training and support plans using HP Quality Center
  • Organized meetings with business users to prepare and update Business Process Requirements and System Requirements.
  • Communicated and managed development efforts with offshore team.
  • When required submitted tickets in iService for deployment application into Model Office and Production environment.

Confidential

Junior Business Analyst

Responsibilities:

  • Created Use Cases, Class, Sequence and Activity diagrams and adapted UML standards to define modularized Data Process
  • Involved in project status meetings, QA review meeting and created test data as required.
  • Extensively completed GAP Analysis between the legacy reports and the New Built report
  • Systematic understanding with enrollment, benefits, utilization management- Authorization, Valid values- Bill type and revenue codes- ICD 9/10.
  • Familiarity of CM/HP algorithms, ICD 10 staging areas, DM episodes, referral interface, user interface and HRA assessment
  • Briefly worked on JIVA health care software made by Zeomega Company

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