SUMMARY

• Seasoned professional with extensive experience in all phases of Software Development Life Cycle (SDLC), including significant skills in requirement gathering, analysis, specification, design, development, deployment, and testing
• Excellent knowledge on Software Testing Life Cycle (STLC) and Bug life cycle
• Proficient in 837 Institutional, Professional Dental EDI Gateways; 834 Benefit Enrolment X12 processing; Pharmacy standard NCPDP files encounters processing.
• Well - versed in loading Medical, Vision and Dental plans in the test environments using plan management tools
• Skilled on working EDIFECS suite with Spec builder, XEnginer server, Transaction Manager (TM) and Enterprise Application Manager (EAM)
• Expert on HL7 data transmission layers and HL7 soup suite
• Adept with X12 and NCPDP (pharmacy) transaction sets and healthcare claims data including various Lines of Business (LOB)
• Expert on multi-level code-based applications like .Net and Java and JMS messaging queue
• Knowledge on Informatica B2B process
• Excellent knowledge on X12 Snip level error of the files.
• Extensive knowledge on Agile and Waterfall methodologies
• Expert in performing System, Integration, Performance, Volume and User Acceptance testing
• Proficient at working Pre-Production and Postproduction Regressions and other testing
• Highly knowledgeable on Medicaid (MMC), Child Health Plus (CHIP), Essential Plan (EP), Qualified Health Plan (QHP), HARP, and Special Need Plan (SNP)
• Experienced at working on SERFF application testing with Centre for Medicaid and Medicare Services (CMS)
• Knowledge on Selenium automation framework using eclipse
• Excellent understanding on EDI Mappings from source to target and guidelines development and modification
• Excellent knowledge and experience with Informatica ETL file parsing and processing
• Skilled on working REST API Services and SOUP UI web services
• Excellent knowledge on HL7 Messaging Interface including TCP/IP, SFTP, HTTPS, AS2 configurations
• Knowledge on TIBCO and MFT file transfer process for end to end transfer process
• Extensive knowledge of Medicaid and Medicare functionality and Medicare programs MEC, Peace Corp, PACE
• Excellent experience on working with Federal agencies like DHS, IRS, Peace CORP, SSA
• Skilled at working on MAEE and HCPCS codes with data stage
• Experienced DataStage side by side testing validation for between cross environments and version upgrades.
• Strong experience at creating and loading QARR file for the quality rating for the plans loaded into the exchange
• Expert in analyzing error response and issue fixes
• Experienced in testing upgrades and changes to ETL migrations
• Highly skilled and knowledge on selenium framework and Java code
• Proficient at coordinating issues with New York State Department of Health (NYSOH) and Electronic Medicaid of NY (EmedNY)
• Experienced in Review and Analyzing Electronic Health Records (EHR) sent by Issuers/Providers
• Adept at working with external vendor, National Association of Insurance Commissioners (NAIC) on plans transferring to New York State of Health exchange marketplace
• Highly experienced at coordinating End to End testing with QA team and developing test scenarios for validation
• Expert knowledge in writing SQL for Database validation and data retrieval for analysis
• Proficient at using Microsoft Test Manager for creating test cases and reporting bugs
• Expertise at designing, developing, implementing, and supporting various EDI transactions and application integration solutions that meet business needs, including transactions to be exchanged between applications
• Knowledge on Informatica, ITX Mapping for data parsing, extraction, and loading
• Extensive knowledge on ICD 9, ICD 10 and HL7 data
• Excellent knowledge and understanding of automation testing procedures
• Strong experience with ESG to MuleSoft migration process
• In-depth knowledge X12 file processing through WTX File processing system to the issuers from exchange
• Expertise on performing multi type testing like Unit, System, Integration, Regression, UAT
• Excellent knowledge on MAEE and QARR file processing through Data stage system.
• Adept in IBM Cognos reporting though oversight process
• Excellent knowledge in understanding use cases and user stories to develop test cases and test scenarios
• Expertise knowledge on preparing test planning and test strategies.
• Highly experience at supporting production systems including analyzing and resolving production problems and end user service requests
• Strong experience in healthcare industry working with various modules using EDI transactions like 837P, 837 I, 837 D, 276/277s, 820, 999, TA1 and 834s which fall under the HIPAA compliance
• Knowledge on creating 834 and 837 files manually as per the HIPPA standards
• Profound experience in understanding and analyzing the differences between segments, elements, loops of various transactions for versions 4010A, 5010
• Adept Tableau reporting on the enrollments and claims and Tableau reporting tool
• In depth experience creating X12 files in both 4010 and 5010 versions for various transactions
• Expertise with structured QA Methodology and QA Process to ensure the Quality Assurance Control
• Adept at communicating with issuer community via phone on electronic data issues to provide Tier II support relating to all EDI tickets and escalating/assigning tickets to different teams according to their expertise
• Excellent communication skills, strong decision-making skills, organizational skills, work ethic, excellent analytical and problem-solving skills.

TECHNICAL SKILLS

Programming Languages: Java, C, PL/SQL, C#, .Net, JMS, JSON

Databases: Oracle11i, 11g/10g, IBM DB2, Dbeaver, Toad, Teradata

Testing Tools: Microsoft Test Manager, Quick Test Pro (QTP), HP Quality Centre, RTC and Rational Quality Manager, Fiddler tool, Snipping tool, SnagIt, Tivoli Workload Scheduler, Serff from NAICS with CMS portal, SOAP UI Web Services, Mobx menu tool, FileZilla, FTP, SFTP, Selenium

Utility Tools: MS Office Suite, MS Project, MS Visio, Notepad ++, Liason EDI Notepad, Citrix Workspace, EDIFECS, Transaction Manager, Spec builder, XEngine Server, Postman, Ready API, HL7 soup, Putty terminal, XML, WSDL

Bug Tracking Tools: Team Foundation Service, Mercury Test Director, Rational Clear Quest, Zira, HP ALM, Rational Quality Manager, Zira

Operating Systems: XP, Unix, Linux, Windows 7, and 10

PROFESSIONAL EXPERIENCE

Confidential

Sr. EDI Engineer

Responsibilities:

• Elicits and communicates requirements for changes to business processes, policies and information systems
• Works on 834 for enrollments and 837 Encounters for Post Adjudicated claims
• Coordinates issues with appropriate departments, performs accurate and timely research, verification, and analysis
• Performs ESG to Mule soft migration process
• Works with business analyst to gather requirements and extract date for the availed resources, and works with Automation team to automate X12 claims running process
• Coordinates issues with New York State Department of Health (NYSOH) and Electronic Medicaid of NY (EmedNY)
• Works on documentation and implementation of changes to the application to the New State of Health Program
• Performs code merge and pre deployment nexus and post deployment merge validations
• Creates X12 files according to business need using companion guide and implementation guides and process through ITX/WTX
• Validates errors generated through response files and fix issues in the file for reprocessing
• Collects and analyses data to evaluate operations difficulties and makes recommendations to solve problems
• Works on HL7 OSI model on multi-layer interface with Get, Post, Put and Delete methods
• Performs various testing like Unit, System, Integration, Regression and UAT on new code development
• Uses SOUP UI services to load plans and hit Federal agencies data services
• Log and track the bugs/defects in the code and work with development team throughout bug life cycle
• Tests well care to fidelis subscriber migration
• Monitor and test Tivoli Workload Scheduler (TWS) processing to move the daily job from Cron to TWS
• Participates in QA team meeting and bug tracking meetings to see the accuracy of data going to Production
• Uses HL7, JMS messaging service to communicate with servers for responses
• Validates notices and communication generated to the enrolled applicants through Market Place of New York State of Health
• Works on X12 and/or NCPDP transaction sets and healthcare claims data including various Lines of Business (LOB)
• Utilizes in depth knowledge of Medicare/Medicaid Claims processes
• Works on 837 Institutional, Professional Dental EDI Gateways; 834 Benefit Enrolment X12 processing; Pharmacy standard NCPDP files encounters processing and 837 Encounters for Post Adjudicated claims
• Conducts meetings with user on business needs and requirements to system changes and upgrades
• Processes different transitions in various environments
• Works with ITX/WTX team for mapping changes or implementation according to business needs
• Provides on call support over the weekends
• Works on loaded Medicaid (MMC), Child health Plus (CHIP), Essential plan (EP), qualified health plan (QHP), HARP, Special Need Plan (SNP)
• Performs security testing to the complex system to ensure safety and integrity of the system
• Creates 834 and 837 files manually according to the HIPPA standards
• Provides support of well care to fidelis migration with SIT and Integration testing
• Works on MAEE and HCPCS codes with data stage
• Uses Excel and beyond compare tools to compare the migration results when systems are upgraded to next version
• Creates and loads QARR file for the quality rating for the plans loaded into the exchange
• Implements NYHX ID to replace subscriber ID for the Department of Health Systems
• Contact’s Issuers/Vendors on file Issues and failure to work for smooth transition
• Validates notices and communication generated to the enrolled applicants through Market Place of New York State of Health
• Generates traceability matrices to ensure that all the requirements are covered by the test cases
• Records, maintains, and tracks defects, assigned type and priority/severity levels
• Utilizes proficiency with regulatory requirements associated with HIPAA and the Affordable Care Act
• Uses EDIFECS tool for validation and analyse Encounters files and Enrolment files
• Works on claims, enrollment, and premium business processes in a commercial, Medicare, and Medicaid health plan/TPA (Third Party Administrator) organization
• Validates X-12 files sent by external vendors to ensure that they are passing WTX Gateway level using Spec Builder
• Generate reports using reporting tool to summarize the file processing flow
• Records, maintains, and tracks defects, and assigns type and priority/severity levels using RQM
• Processes and verifies date loaded into history data like Duplicate, Member and History edits.

Technical Environment: MS-Visio, MS Office, MS Project, RQM, HIPAA/ EDI X12, NCPDP, Oracle 10g, MS Outlook, SharePoint, Oracle SQL, Quick Test Pro, HL7 soup, JMS, REST API, IBM DB2, Ultra Edit, Notepad ++, Liaison EDI Editor, REST API, Quick Test Pro, WTX/ITX 9.0, Transaction Management, Spec Builder, Soup UI, XML, HTML, Fiddler tool, HIPPA Validator, Serf Exchange tool, NYSOH Beat, Beyond compare

Confidential

EDI Analyst

Responsibilities:

• Served as a conduit between the internal, external customers and the software development team
• Used Edifecs software and understood the process of EDI transactions and custom file formats
• Analyzed the errors sent in the file by issuers to the Federal Facilitated Market (FFM)
• Communicated electronic data interchange file failures to the issuers
• Participated in meetings for the changes required for next open enrollment with CMS
• Supported test team on Integration and User Acceptance Tests
• Worked with developers on EDI mapping development along with new guidelines creation and modification of existing guidelines
• Implemented HIPAA EDI Transactions like 270,271,276,277,810,820,834,835,837,999
• Worked on HL7 communication channels, OSI model included Patient demographics and results etc.
• Worked on administration and HUB approval for Adobe Live Cycle to establish relation between HUB and Issuer
• Worked with Informatica ETL team on mapping support and file validation process
• Uses Excel and beyond compare tools to compare the migration results when systems are upgraded to next version
• Participated in weekly calls with CMS on policy and business changes
• Worked on HL7 message service using Edifecs
• Worked on Remedy tickets opened by issuer on X12 and other issues
• Collaborated with internal and external stakeholders to design, develop, test and deploy these solutions
• Worked on 274,810,820, 834, 837, 835, 276 and 277 Institutional and Professional EDI Gateways
• Validated X-12 files sent by external vendors to ensure that they were passing EDI Gateway level using Spec Builder
• Worked on file aggregation and file splitting validations of X12
• Used and tracked transactions status using Transaction Manager (TM) and to monitor trading partner agreements
• Participated on Implementational changes on HL7 file-based processing implementation
• Worked on High glass transactions on payment remittance advices
• Participated companion guide and implementation guide review meetings
• Generated Traceability Matrices to ensure that all the requirements were covered by the test cases
• Supported the data and reporting needs of business owners to enable them to better run their business units
• Worked with Vendor Management, Third Party administrators, Clearing houses and CMS
• Recorded, maintained, and tracked defects, assigned type, and priority/severity levels
• Ensured and tracked volume and quality metrics for B2B enabled customers with emphasis toward compliance
• Communicated
• Researched and established communication channels with organizations that provided EDI insights and direction
• Served as the coordination point for implementations
• Collaborated with cross-functional teams to develop integrated solutions, and with internal and external stakeholders to design, develop, test, and deploy these solutions
• Developed test plan and test cases based on use cases and functional specifications
• Documented, reviewed, and verified testing procedures for compliance to Interface Quality Assurance and Development standards and policies
• Shared expertise with trading partners requesting clarification on EDI standards, file mapping and system logic
• Worked on Administration and HUB approval for Adobe Live Cycle
• Implemented procedures to ensure that B2B support issues were resolved in a timely and professional manner and those issues were properly recorded back to project and issues tracking systems
• Supported the data and reporting needs of business owners to enable them to better run their business units
• Worked on EDI tickets/issues reported by Issuers through remedy system
• Coordinated issues with appropriate departments, and performed accurate and timely research, verification, and analysis
• Collected and analyzed data to evaluate operations difficulties and made recommendations to solve problems
• Maintained, managed, and provided support for all electronic data exchange with B2B partners
• Ensured and tracked volume and quality metrics for B2B enabled customers with emphasis toward compliance
• Supported Test team on integration and User Acceptance Tests
• Worked on XML to X12 conversion validation of file before sending to the issues from Center for Medicaid and Medicaid Service (CMS) and X12 to XML conversion for Issuers
• Communicated with issuer community via phone on electronic data issues to provide Tier II support relating to all EDI tickets and escalated/assigned tickets to different teams according to their expertise, among others.
• Worked on Rest services request with PUT, GET, POST and DELETE to get response from server for faster reponse

Technical Environment: Mark Logic SQL, Remedy, HPQC, Quick Test Pro, MS Word, MS Excel, MS Power Point, MS Access, MS Project, Transaction Management, Spec Builder, HL7 Soup, MS-Excel, Web Services, Web Applications, XML, HTML, HIPPA Validator, Spec builder, Edifecs transaction Manager, Tibco MFT, Remedy, Informatica 9.6, Post Man, SOUP UI, REST API Post Man

Confidential

Software Consultant

Responsibilities:

• Understood Business requirements for HIPAA regulations and policies by coordinating with various Business teams on 834 EDI
• Conducted user interviews, gathered requirements to help create Business Requirement Documentation, using MS Word and MS Visio.
• Reviewed and analyzed the BRD, FRD and detail design documents, and understood the SDLC methodology of the organization
• Worked on HL7 soup for data transmission between entities/organizations
• Tested HIPAA Gateway EDI Transactions, including EDI 837 (Institutional/Professional), 835 (Payment Remittance Advice), 270 (Eligibility Request) / 271 (Eligibility Response), 276 (Claims Status Inquiry Request) / 277 (Claims Status Inquiry Response), 834(Benefit Enrolment and Maintenance Transaction), 278 (Prior Authorization), 997 (Transaction Acknowledgement), 999 (Function Acknowledgements)
• Used Agile Methodology in the process of the project management based on SDLC
• Tested XML files using XML Spy
• Worked on SOAP UI webservices for enrollments XML validation process
• Worked with Informatica ETL team on mapping
• Verified PROD data by executing the SQL commands for data retrieval/verification
• Performed Use-Case analysis using UML, and worked on the flowchart and process diagram along with sequence diagram using Microsoft Visio
• Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 and 5010 standards
• Created and dropped files in informatica file processing location to validate file parsing and processing
• Executed test cases and test scripts for manual and automation testing
• Logged defects in HP Quality Centre/HP ALM for logging, tracking, and reporting bugs in the application
• Tested all HIPAA transactions for multi version support (4010 and 5010) and validated the database to file elements
• Developed and executed SQL queries to verify the proper insertion, deletion and updates into the data warehouse supporting tables
• Participated in the Daily Stand-up meetings
• Worked extensively with ICD Codes, ICD-9 and ICD-10
• Performed Impact and Gap analysis pertaining to 4010 - 5010 conversion to accommodate the ICD-10-CM and ICD-10-PCS code sets
• Analyzed business requirements, performed gap analysis, and segregated them into high level and low-level use cases
• Analyzed data gathered and developed solutions or alternative methods of implementation
• Reviewed requirements and conferred with management and users about format, distribution, and purpose, to identify problems and suggest improvements
• Interviewed Business Users to ascertain functionality, work performed
• Documented findings of study and prepared recommendations for implementation of new systems, procedures
• Prepared manuals and trained users in use of new applications according to organizational policy
• Created Requirements v/s Test Case Matrix in Excel spreadsheet template
• Designed, evaluated, recommended, and approved changes of project during SDLC life cycle
• Coordinated End to End testing with QA team
• Performed User Acceptance testing, developed test logs and opened/closed as and when the issue was fixed, and quality checked with the assumed company data with all the possible test scenarios
• Collaborated with QA team to develop test scenarios for validation
• Created Use Case diagrams, flow chart diagrams and UML models to design the system
• Verified the software application according to the requirement specification (SRS)
• Supported postproduction implementation and production support for 834 EDI transactions.

Technical Environment: DB2, Mainframe, Oracle, Microsoft, XML, HTML, MS-Excel, UNIX, Web Services, Web Applications, SOAP UI, HP Quality Centre, Informatica 9.1, Transaction Management, Spec Builder, EDIFECS, DB2, Mainframe, SQL, Oracle, HL7 Soup, MS-Excel, Web Services, Web Applications. Microsoft Test Manager, Team Foundation Server, READY API, MS SQL Server, Visual Studio Test Manager, XML Editor, HIPPA Validator