SUMMARY:

• PMP certified with 11 years’ experience in Confidential
• Expertise in Medicaid and CHPlus program
• Experienced as Project Lead and System Analyst and involved in project management, requirement gathering, estimation, design and UAT
• Experienced in Facets Reporting and as Data Analyst
• Worked for clients engaged in Behavioral, Medicare and Commercial Health Insurance Policies
• Worked on HMO,PPO and PPFS LOB for Report development/Data Analysis
• Interacted with Clients for Requirement gathering and development of Business Requirement Documents.
• Excelled in Sybase Advantage, SQL server 2005 and Crystal Reports for Reports development.
• Worked on Adhoc Reporting and Automated Reports using SSIS
• Key areas of work in Facets Enrollment,Claims,Capitation,Billing,Provider,Plan,Customer Service, Member/Subscriber,Accounting,Workflow,Accumulators
• Involved in Facets Migration Projects and Health Care Reform Projects.
• Development of reports for HEDIS for quality auditing by CMS
• Sound Knowledge of all Healthcare EDI X12 formats and HCR
• Experienced in Maintaining and enhancing EDI application using Mercator WTX mapping tool
• Knowledge in EDI (HIPAA Gateway,Edifecs,Message Broker,Mercator,EC map)
• Worked on Analysis of 5010 changes and ICD code conversion
• Created multiple FTP and SFTP job for file transfer
• Developed codes on Java platform for generation of reports/extracts from Diamond database

TECHNICAL SKILLS:

Technology: Facets, EDI, Java

Programming Languages: C/C++, Java 1.4, DOS and UNIX Scripting

Database Languages: SQL, Sybase, PL/SQL

Databases: SQL Server 2005,Sybase, Oracle 8i/9

Scripting Languages: HTML

Version Control Systems: MS Visual Source Safe (VSS)

Tools: SSIS,Mercator 6.7 & 8.2,Toad,Pl/SQl developer,FileHandler,Eclipse,Crystal Reports

PROFESSIONAL EXPERIENCE:

Confidential

Project Lead/System Analyst

Responsibilities:

• Analysis of Confidential for Confidential
• Creation of Function design document for the implementation
• Analysis of 834 EDI files from HIX market place
• Analysis of XMS ad Facet data model for file loading and capturing data
• Implementation of CHPlus specific rules for Effectuation, Cancellation and Termination
• Coordination development activities and providing clarification
• Tracking work progress
• Creating Visio s for solution document
• Working with client for understanding requirements and CHPlus specific rules

Confidential

Project Lead/System Analyst

Responsibilities:

• Working on a strategy to deploy a capitated and delegated arrangement with Children’s Mercy Hospital in KS/MO
• Enrollment loading via EEMS(Web service)
• Modification of state inbound 834 legacy process for state specific requirements,
• Implementation of Tiered Provider Service Model (TPSM) level
• State specific claim edits
• Migration of Health plans from Confidential to Confidential
• C&S 2018 DSNP Health Plans implementation on CSP
• New Vendor implementation on CSP
• CSP MPI Matching logic update - Confidential
• Member Premium Payment Online and IVR

Confidential

System Analyst/Project Lead

Responsibilities:

• As a Systems Analyst, been working closely with Confidential business team to come up with design and implementation of various Group load and Member Eligibility load processes in Confidential system between UBH and its trading partners.
• Also for Agate team worked with business team to come up with design and implementation of various Accum exchange process for new business for syncing accum data between the two systems
• Project lead and Point of contact of Confidential Compare team/Agate Team for Confidential .
• Onsite coordination, quality management and team mentoring are some key activities
• As a part of multiple project implementation worked on creating Solution Analysis Impact Evaluation Tool (IET), Solution Summary Document (SSD), System Requirement Inventory(SRI),Technical Design Document and Requirement Traceability Matrix(RTM) and reviewing the same with business for approvals

Confidential

Onsite Co-ordinator/Lead

Responsibilities:

• Worked as a Development Team lead handling multiple development and enhancements project to support Confidential Facets application which includes Core Facets batch, EClaims and Enterprise eligibility.
• Was instrumental in development of multiple interfaces for Confidential from Confidential to Confidential and Confidential platform. Confidential was handled in multiple phases from 2011 to 2013 and was part of all migration phases. Gave guidance for the smooth transition of the Confidential members to Confidential platform and Confidential platform was possible.
• Used UNIX and Sybase tools to answer all business queries related to Facets, to analyze and enhance existing applications, to develop supporting functionalities, to create compliance and regulatory related EDI extracts from Facets tables. UNIX shell scripting, Windows scripting language, XML, XSL, Microsoft Visual Basic and Sybase 12.5.1 database are the technical tools used for the operational activity. Also led and coordinated with Confidential offshore team in India for doing these activities.
• Maintained and tracked deliverables and documents related to development activities using the VSS and ensured standards in all the developments and assisted production support team with deployment of the new developed code into production.
• Introduced the Processing Control Agent ( Confidential ) concept to the business for holding back claims from payment. This has reduced the manual intervention and made the process of denying a claim a lot easier

Confidential

Onsite Lead

Responsibilities:

• Creation of reports and extracts from Facets as per business requirements
• Automation of reports using SSIS
• Development of Crystal reports
• Key areas of work in Facets - Claims,Capitation,Billing,Provider,Plan,Customer Service,Member/Subscriber,Accounting,Workflow
• Involved in Migration of data from Ezcap to Facets
• Development of reports for HEDIS for quality auditing by CMS
• Some notable report developed
• Direct Bill Extract which is used to print the invoices for members
• Monthly Membership Report gives track to business about the count of members across a span of 12/24 month split
• Capitation Extract was pulled from Facets for both standard and specialty capitation and used by Emdeon for printing checks
• Due and Unpaid Premium reports business about members’ dues and undue premium
• Claim Payment Report gives the business all information of claims paid for a given span
• Suspense Billing Report used to report any suspense amount for a billing entity
• Member Provider Network Report which lists the members current PCP, IPA, LPO associated with it.

Confidential

Team Member

Responsibilities:

• Developed stored procedures to load the claims to be reprocessed in customized tables in Facets
• Generating X12 for the claims and running the Facets batches to load the keyword, XC and trueXC in Facets.
• Analysis and modification of stored procedures which are part of EDI CAR process and Claim Adjudication Process.
• Generating a Confidential report of claims from Confidential and main database which are reprocessed.
• As the part of the roll out process, the documentation of the high quality documents containing the details regarding the Reprocessing Closed Out Claims
• Analysis and modification of stored procedures which will be impacted by addition of NHP.
• Modifications of Confidential reports impacted by addition of NHP.
• Modification of Vb form impacted by addition of NHP.
• As the part of the roll out process, the documentation of the high quality documents containing the details and flow diagrams regarding the NHP migration to Facets.
• Creating customized tables in Facets for storing the DW extracts having claim header level and line level details.
• BCP ing the files into the tables.
• Create stored procedures to extract the fields required as per the business need
• Creating. Confidential for the DW extracts
• Modified the Outbound Mercator map to include the NDC code changes, Tenncare Baby Adjustment and 837P J code Denials etc
• Provided support in case of some abends in the regular activities
• Creating Technical documents of various EDI processes.
• Developed batches for transfer of mid files between Tenncare and Confidential
• Developed XML s to pull the file details in the script
• Developed common Vb script to get, put and delete files in FTP and SFTP operations

Confidential

Team Member

Responsibilities:

• Requirement Analysis.
• Creating Technical design documents.
• Coding (involves policy rule coding, sequence flow, status flow).
• Unit Testing
• Code delivery to onsite
• Mentoring new team members
• Handling Domain specific sessions