SUMMARY

• Over 7+ years extensive Experience as Facets Benefit Configuration Consultant in Healthcare Industry with specialization in FACETS implementation and in - depth understanding of Trizetto FACETS data model.
• Strong experience in Health Plan, Member Enrollment, Benefit/Plan/Product Configuration, Provider Setup, Contract Setup, Billing, E2E Claims Processing, EDI Transactions,
• Experience in Health Insurance Portability and Accountability Act (HIPAA), Data Warehouse and working on Requirement gathering, Business Process flow, Business Process Modelling, Data Analysis, Data Mapping.
• Strong knowledge of managed Claims management process, Knowledge of Medicaid and Medicare Services, CMS, Health Assessment Systems, Medicare and Medicaid Insurance Billing, Hl7 Standards, Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, ICD 10.
• Strong knowledge of Facets Data Model and Business Components including Application Support, Claims Processing, Criteria Maintenance, Medical Plan, Provider and Subscriber/Member
• Knowledge and expertise on HIPAA 4010 and 5010, ICD-9 and ICD-10 diagnosis, surgical and procedural codes.
• Strong working experience in the Data Analysis, Design, Development, Implementation and Testing of Data Warehousing using Data Conversions, Data Extraction, Data Transformation and Data Loading (ETL).
• Proficient knowledge of Complex SQL queries using clients like TOAD and SQL Plus.
• Experience with Medicare and Medicaid: Claims processing, Membership, and Eligibility Verification and care management.
• Proficient at creating Use Cases, GAP Analysis, Process Flows & Work-flows using UML and Experience with CRM systems in general (SAP, Oracle, Siebel), ModelN.
• Experience in writing BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Experience in using business modeling tools like MS Visio and Unified Modeling Language (UML) for creating Use Case Diagrams, Business Process Models, Process Flow Diagrams, Class Diagrams, Activity Diagrams, Sequence Diagrams, and workflow diagrams.
• Expertise in reviewing Test Procedures, creating Test plans, defining System & Integration Test Cases, executing Test Cases, Test Data reviewing and maintaining and executing detailed Test scripts for User Acceptance Testing (UAT), analyzing bugs, interacting with team members in fixing.
• Experience in Gap analysis to compare as-is with to-be business processes and worked with technical resources to draft one or more solutions so that pros and cons can be presented to the business.
• Skilled in Software Development Life Cycle (SDLC) phases such as planning, analysis/design, development, and testing.

TECHNICAL SKILLS

Industry Standards: HIPAA 5010, ICD 10, ICD 9, PPACA (Patient Protection and Affordable Care Act)

Databases Access: Oracle 8i/9i/10g, Teradata V2R5.1, DB2, MS SQL Server.

Other tools: Informatica, Load Runner, Win Runner, Crystal Ball, Expert Choice, Core, Caliber

OLAP Tools: Business Objects XI, Cognos

Testing tools: Rational Robot, Rational Clear Quest Test Manager, HP Quality Center, Quick Test Professional (QTP), LoadRunner, WinRunner Apps & Webservers Apache web server, Tomcat, Web logic 8.1, IIS.

Methodologies: Agile, Waterfall, RUP, UML, SDLC, Scrum, V-shape modeling

Change Management Tools: Rational Clear Quest, Rational Clear Case

Business Modeling & Versioning Tools: MS Visio, Visual Paradigm, Rational Rose; Rational Requisite Pro, Rational Clear Case

MS Office: MS Project, MS Word, MS Excel, MS PowerPoint, MS Access, Infopath Designer

Programming Languages: Structured Query Language (SQL)

PROFESSIONAL EXPERIENCE

Confidential - Baltimore, MD

Facets Configuration Consultant

Responsibilities:

• Responsible for the configuration and oversight for Facets related upgrades enhancements and new application development that is under the direction of the Facets Business Support Team.
• Involve in Facets 5.30/4.81/4.41 , with deferent modules like Subscriber/Member, Open Enrollment, Claims Processing, Networ X, Billing and Providers Applications.
• Involve in to update the Supplemental Rev Code Conversion and Supplemental Procedure Code Conversion tables.
• Building Medicaid and Medicare Advantage Plans End to End using all related Facets Applications including Member/Subscriber, Accounting, Criteria Maintenance, Provider, Application Support, Medical Plan, Medical/Hospital Claim Processing.
• Involving in business discussions to understand billing and finance requirements for Medicaid membership migration.
• Design and implement HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction, Populated ICD-9, NDC Disease code sets as per the standards. Experience with transaction sets 835, 837, 270, 271, 276, 277 and 5010.
• Validating the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Configures, tests and documents configuration solutions for the benefit, authorizations, and claim rules and regulations
• Involve Validations for Electronic Claims: EMC, UB04 and CMS 1500 for Hospital Pended Claims Report and Accepted Claims by Tax ID Report.
• Resolve Claims Errors and Configuration updates through analysis and configuration design to promote Claim Auto Adjudication; create Desk Level procedures for Manual Claim Adjudication
• Involve in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Performing analysis in Membership and billing data from Facets.
• Adjust Business Rules, Processes, and Data Transformation Language code, modifying, testing, and troubleshooting HL7 interfaces as needed.
• Provide various strategies to implement HIPAA 4010 in the new MMIS system and ultimately move to HIPAA 5010.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team
• Analyze CMS reconciliation data with CMS monthly claims file and prior reconciliation periods.
• Map provider data from source to target Facets data layout for the claims and benefit configuration.
• Reviewed rate filing for CMS and proposed changes to the quarterly premiums and cost and utilization rates.
• Provide solutions on Claim Processing Application for the implementation of HIPAA mainly used for AR (Accounts Receivable) claims.
• Coordinate with state stakeholders on Medicaid Management Information System (MMIS) portal development.
• Consult and collaborate with the Centers of Medicare & Medicaid Services (CMS) to analyze federal guidelines pertaining to Medicare fraud and abuse to ensure program compliance and protection of the Medicare Trust Fund.
• Conducts end to end testing and developed integrated changes for CMC to Facets Implementation
• Create and execute Unit and SIT/UAT test plans, test scenarios and test cases; resolve and track defects in HP Application Lifecycle Management.
• Configures benefits and inputs group business data into pertinent systems, including rates, benefits, ASO billing arrangements, agent/marketing personnel in specified time frame.
• Create and run queries via Microsoft Access and SQL; use Microsoft Access and SQL to research and load data backend.

Environment: Oracle9i, Java, SQL, Oracle, MS Office, HEDIS, FACETs, Rational Rose, MS Visio, MS Project, UML, HP ALM, Oracle, PL/SQL Microsoft Excel, Microsoft Word, Microsoft Power Point, Requisite Pro, RUP, MS Office (Word, Excel, Access, PowerPoint, Visio), SQL, Java, Windows 2000/NT.

Confidential - Minnetonka, MN

Facets Configuration Analyst

Responsibilities:

• Tested the enhanced FACETS evaluating claims adjudication needs and created HIPAA-compliant business rules configuration.
• Worked on multiple reports on Membership, Group/Class/Plan/Product, Providers, Claim Processing, Premium Rates, Billing and Commission modules from both Facets and hpXr.
• Involved in the Development of business rules and testing for HIPAA compliance certification of healthcare standards.
• Directed the implementation and compliance of Recovery Audit Programs addressing Medicaid and Medicare Parts C and D under the Affordable Care Act (ACA).
• Analyzed, and documented business and functional requirements via uses cases for Medicare billing transaction-based middleware/database layers with SOA & XML.
• Resolved Claims Errors and Benefit configuration updates through analysis and configuration design to promote Claim Auto Adjudication; created Desk Level procedures for Manual Claim Adjudication
• Providing enrollment for all Medicaid providers along with the Medicaid Member. This includes the files and data conversion and migration of all application functionality from the legacy MMIS system to the client-server application Health PAS system.
• Contributed as part of a team that reviewed and evaluated confidential information pertaining to CMS' needs
• Direct the activities of teams responsible for Revenue Cycle system and end-user support, including ICD 9/10, HIPAA 5010, HL7/EDI exchange, project management, and end-user training.
• Worked with development teams on HL7 data workflows from software EDI to insurance payers; analyzed paid claims and denied claims.
• Corresponded with and generated reports for DOI and CMS to satisfy regulatory reporting requirements
• Test scenario development and Defect Management using HP ALM.
• Worked on dual coding the accounts in ICD-9/10 to validate the specificity and accuracy of the system and its impacts from the Billing and Claims perspective.
• Previously assisted with implementation of new healthcare data warehouse and currently designing new reports around new features.
• Reviewed and updated Service ID Descriptions application to compliment applicable Medical Plan benefits
• Created and updated Service and Revenue Supplemental Tables.
• Modeled data using MS Excel, Access, SQL, SAS, and/or other data warehouse analytical tools.
• Configured, built and tested benefits in PowerSTEPP for new business and renewals. Reported and updated data to ensure proper configuration process.
• Worked as a Business Analyst for multiple module wise development teams. The project followed full project life cycle as per the SDLC specifications using MS Project.
• Communicated twice a week with business SMEs and Project managers to solidify requirements and associated deliverables.
• Worked with the business team for the project requirement review and User Acceptance Testing (UAT).

Environment: Rational Rose, MS Visio, MS Project, UML, HP ALM, Oracle, PL/SQL Microsoft Excel, Microsoft Word, Microsoft Power Point, Oracle9i, Java, SQL, Oracle, MS Office, HEDIS, FACETs.

Confidential - Philadelphia, PA

Healthcare Business Analyst

Responsibilities:

• Acted as a liaison between the company and the business partner in support of gathering and documenting requirements, developing process flows, writing use cases, specifications and in writing user guides to meet project objectives.
• Followed RUP quality Assurance and Testing Process. Interfacing with program management and executive teams regarding quality assurance goals.
• Matched the requirements for programs such as Medicare and Medicaid which are part of the Social Security Act.
• ICD10 Field Expansion: Migration of HealthCare ICD9 to ICD10 diagnosis codes which is the key aspect in healthcare domain.
• Validate data load processes and the quality of the data loaded into Electronic Data Warehouse.
• Adhered to the HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.
• Worked on Requesting enrollment of subscribers in FACETS by filling membership request form for different Plans and products
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database Maintained the requirements traceability matrix and ensured that the requirements were consistent after changes.
• Collaborated with data warehouse QA team to ensure seamless execution of test cases end-to-end
• Ensured a high level of data quality including data analysis, creation of scrubbing and augmentation rules and data quality reporting.
• Prepared an ROI analysis report after evaluating the COTS product of the multiple business lines
• Consolidated the analysis of multiple business lines after the COTS evaluation.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA
• Gained experience on Quality Center, Microsoft Outlook, Lotus Notes, Microsoft Word, Microsoft Excel,
• Worked with HIPAA rules and regulations to draft business rules and claim processes.
• Created Use Cases, Use Case Diagrams, Activity Diagrams to demonstrate software architecture and interaction of system components before prototyping.

Environment: Requisite Pro, RUP, MS Office (Word, Excel, Access, PowerPoint, Visio), SQL, Java, Windows 2000/NT, UML, Oracle9i, Java, SQL, Oracle, MS Office, HEDIS, FACETs.

Confidential - Phoenix, AZ

Business analyst

Responsibilities:

• Analyzed user requirement and impact on exiting system caused by proposed changes and defined business needs.
• Delivered the comprehensive Functional Specifications and System Design Specifications (SDS) and System Requirement Specification (SRS).
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams.
• Conducted User Acceptance Testing (UAT) and collaborated with the QA team to develop the test plans, test scenarios, test cases, test data to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Worked closely with the Developers and Engineering Teams in the review and modification of the product and its specifications.
• Maintaining a Traceability Matrix to ensure that all Functional Requirements are addressed at the Use Case Level as well as the Test Case Level.
• Mapping client's requirements and providing them with the best IT solutions involving evaluation and definition of scope of project.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams

Environment: SDLC, Agile, Scrum, UML, Clear Case, XML, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), MS Access, MS Project, MySQL, Requisite Pro