EDI Claims Analyst Resume

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