SUMMARY

• Over 7+ years of extensive Experience as Facets Configuration Consultant in Insurance and Healthcare Industry with specialization in FACETS implementation and in - depth understanding of Trizetto FACETS data model.
• Experience with TriZettos Facets Application Groups: Claims Processing, Claim Pricing, Provider network management and Reporting, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Strong knowledge of Facets Data Model and Business Components including Application Support, Claims Processing, Criteria Maintenance, Medical Plan, Provider and Subscriber/Member.
• Experience working with HIPAA ANSI X 12 4010/ 5010 , 834, 835, 837 for institutional, professional and commercial claims, and up-gradation of ANSI 4010 to ANSI 5010. Excellent understanding of ICD 9, ICD 10, HCPCS, and CPT Codes.
• Well known with flow of EDI transaction processing through trading partner to the core database and also know the process for External database for the facets system.
• Extensive knowledge of Electronic Data Interchange (EDI) Transactions ex. 837, 835, 276, 277 etc.
• Experience with TriZetto Facets and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• 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).
• Experience with Medicare and Medicaid: Claims processing, Membership, and Eligibility Verification and care management.
• Strong experience in Health Plan, Member Enrollment, Benefit/Plan/Product Configuration, Provider Setup, Contract Setup, Billing, E2E Claims Processing, EDI Transactions,
• Experience in HIPAA, Data Warehouse and working on Requirement gathering, Business Process flow, Business Process Modelling, Data Analysis, Data Mapping.
• Functional experience in Claim Life Cycle and Health Care Payer domain process along with various line of health insurance system like PPO, HMO, POS.
• Gained extensive knowledge and understanding of MITA, MMIS, Electronic Medical Health Record (EMHR) and Pharmacy Benefit Management (PBM).
• Proficient knowledge of Complex SQL queries using clients like TOAD and SQL Plus.
• Experience in closely working with all levels of stakeholders and SMEs including CEO, Regional Medical Directors, Health Services Directors, providers, General Managers of the markets, Clinical Services Directors, departmental directors, compliance officials, medical coders, CTO, product managers, software developers, testers, system trainers and technical support staff.
• Working knowledge of programming languages such as VB, Java, .Net, Delphi and XML, relational database management system, HL7, EDI and writing SQL queries to perform basic database operations to pull the data and create ad-hock reports for the business users.
• 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.
• Proficient in Developing and executing Test Plans, performing functional, usability testing and ensuring that the software meets the system Requirement.
• 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.
• 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.

TECHNICAL SKILLS

Industry Standards: HIPAA 5010/4010, ICD 10, ICD 9, PPACA (Patient Protection and Affordable Care Act)

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

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.

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

OLAP Tools: Business Objects XI, Cognos

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

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

Programming Languages: Structured Query Language (SQL)

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

PROFESSIONAL EXPERIENCE

Confidential - Birmingham, AL

Facets Configuration Consultant

Responsibilities:

• Involved in Facets 5.30/4.81 with deferent modules like Subscriber/Member, Open Enrollment, Claims Processing, Networ X, Billing and Providers Applications.
• Designed and Developed an Informatica Mappings which generate an XPF Key Word File (Target Flat File) which will be loaded into the target tables using Facets XPF import batch job.
• 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.
• Configured, tested and documented configuration solutions for the benefit, authorizations, and claim rules and regulations
• Involved in the Validations for Electronic Claims: EMC, UB04 and CMS 1500 for Hospital Pended Claims Report and Accepted Claims by Tax ID Report.
• Documented the impact of migrating from the HIPAA 4010A1 transaction set to the HIPAA 5010 transaction set.
• Have done analysis on HL7 that establishes criteria for representing and communicating data associated with health care.
• Worked on EDI X12 transactions, HIPAA standard transaction codes including 837, 835, 834, 270, 271, 276, 277, 278 and performed analysis and testing of such transactions.
• Validated the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Built 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.
• Worked on the three components of HL7 EHR system functional model and standard, functions within model, and content management components.
• Worked on design documents related to Membership Eligibility Information file / interface, feed to PBM system for PDP migration in Medicare Part D project.
• Involved in the analysis on conversion of Claims and Members files from legacy systems into Facets and to its downward systems.
• Resolved Claims Errors and Configuration updates through analysis and configuration design to promote Claim Auto Adjudication; create Desk Level procedures for Manual Claim Adjudication
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Performed Facets Data Analysis and data mapping between Facets Data elements and downstream system's requirements.
• 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.
• Updated different Interface design documents and Mapping documents to satisfy business needs for advancing the PDP migration project.
• 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
• Analyzed 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.
• Consulted and collaborated 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.
• Provided Technical inputs from Facets perspective in the BTRD completion process for satisfying the downstream system's needs especially to PBM.
• Extensively involved in Membership Enrollment and Billing area by updating the Design and Mapping documents based on BTRD and through Change Requests / SSCRs as required to downstream systems.
• Extensively involved in Facets billing module mainly in Back - End system process for membership's enrollment info to downstream system
• Designed Billing History, Enrollment Reconciliation Process, Eligibility Feed.
• Involved in the Data Migration meeting and process to provide feedback from Facets side based on its technical functionality.
• 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.

Confidential, NY

Facets Configuration Analyst

Responsibilities:

• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, premium billing, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system to FACETS.
• 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
• Tested the enhanced FACETS evaluating claims adjudication needs and created HIPAA-compliant business rules configuration.
• Worked on Member Management, Eligibility, Claims, and Provider modules within FACETS.
• 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.
• Collected the information related to ongoing application upgrade and their impact on implementation and impact, benefits and risks of ICD-10 code application. 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.
• Re-Organized the collected data and prepared documentation for implementation.
• Facilitated data mapping activities and helped with the expansion of membership and provider data model.
• Created workflow diagrams, process flow and data flow diagrams. Assisted team with Data Mapping and Data Extracting Strategies for data migration.
• Worked with development teams on HL7 data workflows from software EDI to insurance payers; analyzed paid claims and denied claims.
• Configured, built and tested benefits in Power STEPP for new business and renewals. Reported and updated data to ensure proper configuration process.
• Involved in creating use case diagrams for the purpose of the team to understand the workflow of the system.
• Analyzing the business needs for the reports and documenting the requirements in SSRS forms.
• 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.
• Providing enrollment for all Medicaid providers along with the Medicaid Member. This includes the files and
• 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
• Modeled data using MS Excel, Access, SQL, SAS, and/or other data warehouse analytical tools.
• 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).

Confidential - Franklin, TN

Healthcare Business Analyst

Responsibilities:

• Performed GAP analysis and analyzed EDI 837 (Health Care Claim) transaction and benefit structures in claims transactions from HIPAA .
• Worked with Trizetto Facets for the Billing and Enrollment Process.
• Developed crosswalk between ICD-10 and ICD-9 to assist with transitioning to ICD-10 and identify the differences between the two versions.
• Worked on Requesting enrollment of subscribers in FACETS by filling membership request form for different Plans and products
• 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.
• 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.
• 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.
• 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
• Worked with HIPAA rules and regulations to draft business rules and claim processes.
• Conducted JAD sessions involving SME's, business users, data administrators, system architects, managers and development team in order to create a good business process model.
• Identified the project scope, business objective, feasibilities and risks based on Scope/Vision documents particularly related to Medicare, Medicare Advantage Plans, Medicaid Eligibility and Child Support and Assistance.
• Followed RUP quality Assurance and Testing Process. Interfacing with program management and executive teams regarding quality assurance goals.
• 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.
• Gained experience on Quality Center, Microsoft Outlook, Lotus Notes, Microsoft Word, Microsoft Excel,
• Created Use Cases, Use Case Diagrams, Activity Diagrams to demonstrate software architecture and interaction of system components before prototyping.
• Reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly. Functional testing of the application was performed as per the ICD10 changes. Involved in ICD coding and mapping.
• Developed various use cases to come up with the front-end application design.
• Worked with ALM analysts, SME's and high level regulatory managers to identify data elements and report types
• Identified bugs during the test phase and reported them using ALM.
• Helped in conducting User Acceptance Testing (UAT), Unit and System Integration testing (SIT).

Confidential - Salt Lake City, Utah

Healthcare Business analyst

Responsibilities:

• Worked on claim processing receipt and verification of the claim forms (837) and claims attachments (275), claim Enquiry and Response (276/ 277).
• Oversee the EDI process, working directly with trading partners to enhance the secure and HIPAA Compliant electronic flow of information.
• Responsible for Claim Editing due to data entry error, enrollment adjustments, configuration errors etc.
• Conducted Claim Validation and Verification and Billing and Enrollment Process together with FACETs Team in compliance with HIPAA guidelines.
• 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.
• Maintained the Traceability Matrix to trace the identified business requirements against functional requirements to use case.
• Attended daily SCRUM and guided QA and Developer regarding the defects, technical specification Documents and Mapping documents.
• Involved in drawing data flow diagrams and process flow diagram using MS Visio for claim adjudication module.
• Created UML based diagram: Use Case diagrams, Sequence Diagrams, and Activity diagrams using Rational Rose and MS-Visio.
• Participated in entering, tracking system defects using Rational Clear Quest.
• Involved in Configuration Management, Requirement Management and analysis.
• 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.
• 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.
• Conducted Brainstorming and Facilitated Joint Application Development (JAD) session.
• Prepared Business Requirement Documents, Functional Requirement Document, and Non-functional Documents from the gathered requirements.
• Had worked on business planning and consolidation using MS Excel (Office Analysis).
• Adopted AGILE methodology throughout the project.