PROFESSIONAL SUMMARY:

• Confidential is an EDI/Business/QA Analyst with 8 years of hands on experience in Project Management including staffing and coordinating software development projects.
• Knowledge of health insurance concepts such as Medicaid/Medicare Part A, B, and D.
• Knowledge of Mainframe
• Testing, troubleshooting and supporting of EDI files.
• Troubleshooting Healthcare EDI transactions
• Strong experience with different project methodologies including Agile, SDLC
• Proficiency in Microsoft software applications such as Word, Excel, PowerPoint, Access, Outlook, Visio and SQL
• Knowledge of data processing systems and hardware particularly personal computers.
• Knowledge of telecommunication data delivery methods and telecommunication software and concepts such as NDM, FTP, SFTP and dedicated connections.
• Experience in the implementation and maintenance of trading partner accounts in a high - volume, high-paced operation using flexibility in terms of managing many accounts with unique requirements.
• Working knowledge of EDI data translators and validation support, i.e., Gentran and Faciledi.
• Ability to communicate effectively with all levels of management and communities.
• Adapting to new and fast changing technologies. Ability to handle multiple tasks with competing priorities.
• Work effectively, both independently and in team setting, with individuals having diverse professional background including business, technical and corporate health organizations.

PROFESSIONAL EXPERIENCE:

Confidential, New York, NY

EDI Analyst/Project Manager

Responsibilities:

• Monitoring the uploading and downloading of eligibility files between mainframe and PC including compiling error reports and communicating with Trading Partners, Vendors, Medicare contractors, and CMS to resolve.
• Troubleshooting and facilitating the resolution of any identified data file transmission and transaction errors including verification that all communication links and interfaces are working correctly and communicating appropriately.
• Working with management to establish, document and maintain EDI procedures by identifying errors and taking corrective action, reconciling EDI transactions through coordination of information with internal and external customers, Accounting Department, IT Department and external vendors to maintain EDI integrity.
• Conducting regular audits of EDI transactions to determine accuracy and areas for improvement and maintaining EDI maps and business rules for HIPAA validation software.
• Monitoring the daily receipts and processing of claim files from Medicare contractors along with troubleshooting and resolving data transmission or content problems.
• Performing analysis based on claim crossover inquiries related to eligibility files and billing.
• Identifying, establishing and maintaining business relationships with internal and external trading partners and business partners.
• Performing other duties in support of the organization/EDI mission as directed by management.
• Coordinating tasks with Confidential Data Collection partners to ensure that all EDI information is correctly formatted to enable us to provide an accurate Response File back to complete the transaction.
• Assisting the IT Department by performing User Acceptance Testing on system enhancements prior to being moved into production.
• Assisting in the development and updating of educational material for the COB Secure Web Site for all EDI Activities.
• Closely working with external customers to ensure they have a smooth transition from testing to production.
• Monitoring external customer to ensure testing is completed in the timeframe allotted.
• Responding to CMS inquiries

Confidential, New York, NY

EDI Specialist/Systems Support

Responsibilities:

• Streamlined the claims payment process.
• Provided quality customer service.
• Maintained the integrity of the Medicare trust funds.
• Testing, troubleshooting and supporting of EDI files.
• Troubleshooting Healthcare EDI transactions.
• Identifying situations where another payer may be primary to Medicare.
• Confidential Helpdesk/Troubleshooting in-bound calls from Internal and External Customers.
• Heavy interaction with internal/external community to assist with Web Application and Electronic Media Questionnaire (EMQ) process within the COBSW Web portal.
• Responsible for HIPPA compliance maintaining PHI, PII, FTI confidentiality for data security for GHP and NGHP to insure CMS/SSA/IRS agencies data sequencing.

Confidential, Philadelphia, PA

EDI Analyst

Responsibilities:

• As an EDI QA, for the Confidential -PM, actively involved in the Requirements analysis, Functional System Design, UI Specifications, System Test Planning and Execution for the Plans and Benefits Module for Qualified Health Plan (QHP) Application
• Identify and act on necessary corrections and improvement/efficiency opportunities.
• Accountable for the development of release Test Plan and the post-implementation report.
• Prepare test estimates and project schedules.
• Track the execution of the release-testing schedule.
• Participate in all Scrum processes including sprint planning, daily stand-ups, reviews and product demonstrations.
• End to end testing on Confidential Obama Care (Affordable Care Act) and Marketplace
• Responsible for the release defect management. Responsible for preparing the final go/no go release recommendation.
• Performed in the End-to End Testing of Web services to implement Confidential policies.
• Serve as an escalation path for QA Production Support activities.
• Mentors less experienced Team Players on QA best practices and methodology.
• Work with leadership to define the QA strategy.
• Worked in the area of Healthcare Insurance provisioning solutions in light of industry transformations due to Affordable Care Act.
• Develop documents and maintains the QA methodologies, processes and procedures.
• Provide career and technical advice to QA Team Players.
• Utilize tools and methodologies to improve individual effectiveness and to increase efficiencies in the QA process. Identify trends and implements corrective actions.
• Review requirements and specifications to identify potential risks to quality, identify ambiguities or omissions, and ensure testability. Work with project team to recommend and implement steps to mitigate identified risks.
• Design, develop and execute test plans and test cases.
• Contribute to functional, integration, certification, and regression testing, and work closely with specialists in areas such as accessibility, security, and performance.

Confidential, New York, NY

EDI Analyst

Responsibilities:

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements.
• Involved profoundly in the GAP Analysis of Employer Rosters, Employee and Employer Application Fields focusing on changes required in existing COTS products to meet client business needs.
• Worked on streamlining SharePoint to meet project policies and processes.
• Performed Data Mapping for State Administration Enrollment Management function to define the data elements, their source and read only/editable parameters.
• Documented and Analyzed impact upstream and downstream when change in editable data elements in State Administration Enrollment Management function is recorded.
• Documented the "Configure Billing Cycle" scenarios and billing rules for the employer.
• As the processes and methodology moved from waterfall towards agile, wrote requirements in form of User Stories and Acceptance Criteria Documentation.

Confidential, Columbus, OH

EDI Analyst

Responsibilities:

• Analyzed Business Requirements, developing tracking and enhancing them into functional requirements using Rational Requisite Pro as a requirements tool.
• Gathered the requirements and transformed them into high-level Process-Flow Diagram using PowerPoint.
• Involved in preparing Test Plans based on User Requirements Document (URD) and prepared the Test Cases using Test Director/HP Quality Center.
• Created mapping/crosswalk documents for mapping data flow between systems.
• Identified and documented in the test plan, dependencies between the business processes.
• Responsible for the full mapping, implementation and testing for accurate accumulators update.
• Developed the business anomalies workarounds and described them in documentation and presented the matter to the upper management for review using SharePoint.
• Define and develop process flow charts for all EDI applications
• Reviewed extensive SQL Queries with complex multi-table joins and nested queries
• Acted as a SME for the application team and the Infrastructure team.
• Efficiently accelerated planning schedules so as to adequately manage release timelines
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents.
• Held regular meetings with the system architects, developers, database developers, during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Hosted the application online using Microsoft share point excluding some functionality those were developed to use by employees only.
• Performed configuration/ compatibility and user interface testing.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual(s) for resolution.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release