PROFESSIONAL EXPERIENCE

• Have 9+ years of Experience in Healthcare Industry Operations and IT (Claims submission and Data Analysis, auditing, ICD9/10, CPT, Modifiers, Medical Records check, Project Management and Team Handling, System analysis, determining teh functionality, API key analysis, Swagger analysis), 3+ years in SQL, 2+ Years TABLEAU and 12+ years in Microsoft Excel (Pivot Tables, V - LOOKUP'S) and4years of education in Professional management plus Pursuing Doctorate in Healthcare Administration.
• Good Hands on Experience working wif Microsoft Suite 2010 (Analysis Reports, Pivot Tables, all type of Graphs) and Extracting Reports by using SQL Queries against database and Data Visualization wif Tableau, Confluence and JIRA.
• Have good hands on Experience wif Misys, Jacada, All Scripts, GBD Facets, Compass.
• Strong experience in working wif SOAP services and REST API keys to analysis for values it bringing.
• Consuming Web Services in current application and making sure to do not have performance issue.
• Very good hands on experience how API keys will work when changes required and from which system API should bring teh values.
• Worked for “WellPoint Group Systems” - for Claims, Enrollment, Billing and Authorization/Referral forms.
• Worked for TPA, Healthcare / Medical Claims and its analysis, Claims Database settings, Report generation, ICD9 / ICD10, Enrollment and Eligibility status, Clinical (Pathology and Radiology) data and Project all teh reports to teh Client and management.
• Worked wif EDI Claims system for HCFA and UB (835, 837I and 837P X12).
• Hiring, Training and giving feedback to Direct Manager for appraisal activity for every year.
• Have good experience wif MS Excel Pivot Table, Graphs and Data Analysis.
• Good hands on Experience wif All scripts, Mysis (Billing Software), Main frame (Enrollment Software and Claims Adjudication), Jacada (Claims Adjudication), Provider Network and Health Insurance Database.
• Handling Data Governance - Clinical Data, patient Encounter Data, claims data, Enrollment data, Provider Data, Healthcare Plans data and benefits data.
• Have Good noledge about Clinical data integration, Migrating from System to System.
• Have good noledge about Transferring data through Cloverleaf Bridge.
• Have Good noledge about HL7 (Health Level 7, Messages transferring from System to System).
• Have good hands on Experience to work wif Misys, Medical Management, Mainframe, All scripts (Claims billing software) and Jacada (Claims Adjudication Software).
• Have good Experience to work wif CPT, HCPCS, ICD9 /10, Modifiers, AR team, all teh corners of Medical billing and claims adjudication systems and Management.
• Have Good Knowledge about Python and SAS and Exporting Files into SAS Environment and Making reports.
• Have very good understanding and noledge about Cloud environment, Cloud deployments and Cloud server to work on it. Worked wif AWS server and IBM server.
• Good Project Management, Team management and Deliverable Skills on time, Client consulting Experience too.

PROFESSIONAL EXPERIENCE

Confidential

Product Manager/Lead Business Architect

Responsibilities:

• Working as a liaison between business and IT team to deliver teh requirements for product.
• Working wif PEGA technology in Agile process.
• Gathering requirements for Provider Life Cycle Management (PLM)
• Working wif Version One.
• Handling On shore and Off shore team.
• Working for Hospitals and Provider data to set up in PLM application.
• Verifying teh provider data to be accurate and to insert into teh application.
• Working wif robotics process to update teh provider details to Enterprise system and bringing teh values from other systems.
• Working wif SQL.
• Working wif Data Governance for Provider Contract agreement and providers benefits along wif Claims data.
• Working wif Web-services analysis to identify teh correct value bringing from legacy systems.
• Working wif all stakeholders for provider contract enroll and approval process.
• Working wif off shore and on shore team to deliver teh project on time.
• Analysis of root cause for all business issues (provider data, enrollment data, claims data, UM etc) resolving all issues.
• Gathering all teh requirements from every source and stake holders - converting them into business functionalities- creating user stories.
• Grooming all user stories wif where service dependency requires and wat would be teh UI design to all Dev and QA team to be Developed and tested before releasing teh feature into market.
• Closely working wif all stakeholders to get all teh requirements and creating user stories.
• Delivering all functionalities to Dev team to develop and QA team to test teh function.
• Participating in UAT testing and Validation of feature post to teh deployment.

Confidential

Product Manager

Responsibilities:

• Worked for Marketplace, Medicaid, Medicare and Duals Appeals and Grievances for Provider and Member cases.
• Worked for Digital cases pulling into new application and integration and mapping all teh fields of values in new system.
• Progressed to standardize teh process from legacy systems to PEGA applications
• Prepared use cases and detailed user stories to halp Developers to understanding teh functionality of that feature and Technical requirements (web services, DB changes).
• Maintained all Epics wif full functionality and kickoff as expected due date wif good quality.
• Worked wif All Stake holders to gather requirements and Giving demo to Executive team for teh product developed and functionality for each end of teh sprint.
• Good experience wif Product Management and SDLC drive path to release product.
• Converted business requirements to Technical requirements and explaining those to Dev team and QA team.
• Drawn Work flow diagram and making project FRD and BRD documents converting them to Technical requirements and making user stories for developers and Business.
• Prepared deliverable documents about Project in Agile environment for every sprint.
• Worked wif all NCQA categories to map as per teh Member and Provider cases types requirements.
• Planned for all teh works (Dev and QA to Release to Prod). Road mapping and planning for Handling Production errors.
• Worked wif CRM system to pull teh cases into PEGA. Working wif CRM to create test cases and contact wif enterprise system.
• Handled Data Governance - Appeals and Grievances for Provider cases and Member cases, Referral data, Authorization data, Claims data.
• Healthcare Data Analysis for HCFA and UB claims.and Mapping for Member enrollment data, Claim data, Referral form, Authorizations data, Provider Network, Member Demographic Information, Treatment related data (Clinical data Such as CPT, Modifiers, Diagnosis Codes (ICD9 and ICD10), Revenue codes.
• Worked wif SQL
• Prepared screens and submitting to client upon approval developing teh screens as client expected.
• Worked API / SOAP Web Services analysis to capture teh correct data and to display in application.
• Analyze teh Data before we fetching into new application.
• Suggested to client based on new requirements information how teh present system handling and how it’s need to be in new application.
• Developed PEGA UI and analyzing teh Healthcare data at all stages and every data elements.
• Worked for Appeals and Grievances project into PEGA.
• Worked wif A&G data from Source system to fetch teh data into PEGA
• Solved all teh problems from Dev and QA team wif application behavior and Integration information and DB pointing to.
• Based on requirements gathered analyzing teh application behavior, solving all teh questions raised by team members.
• Handled Onshore and Offshore team, supporting wif all required information and explaining teh features to be Developed and tested.
• Worked to configure teh SLA for each and every case types and analyzing how SLA varying case to case how to implement in PEGA .
• Worked for Market place, Medicaid, Duals (MMP) and Medicare Managing EPMO and Government LOB’s..
• Giving Demo to Business team and Senior Leadership team about developed features and upcoming features.
• Trained Teams wif all teh business functions and case processing for business support in production environment
• Adhering to Healthcare HIPAA rules and CMS Guidelines proposing Business requirements and solving all issues wifin teh organization.

Confidential, Virginia Beach, VA

Sr Business Systems Analyst -Product Management

Responsibilities:

• Working as a Senior Systems Analyst in Agile methodology environment for Member Enrollment, Claims, Provider Lookup, Provider Network details, Authorization search and Benefits summary.
• Leading teh Team by providing all teh necessary requirements and giving teh Test data to test teh functionality of Application
• Worked wif PEGA applications. Good experience wif SDLC.
• Worked wif WellPoint Group Systems- Claims, Billing, Enrollments and Referrals.
• WGS system is teh source system to bring all teh field values to Newly designing PEGA application.
• Good hands on experience to work wif SQL database to pull teh required data.
• Working for all teh Business developments for all Commercial insurances.
• Analyzing teh current system wif enabling all teh features and benefits of another system.
• Lead teh team by providing all teh necessary information to develop teh application and make it function as expected by teh Business team.
• Good hands on experience wif JIRA, Confluence, COMPASS and GBD Facets.
• Good understanding about Facets and it’s design.
• Worked wif Facets to get teh values for extending application support (PEGA application).
• Good hands on experience on Facets design and Database structure for Claims, Member and Provider data information.
• Created User stories and explained them to Dev and QA teams to understand wat needs to be accomplished and wat needs to be tested where it will impact in teh developing application.
• Tracking all teh user stories work and signing to kickoff user stories for each wand of teh sprint
• Worked wif NASCO data and Analysis
• Worked wif WHS System which is Mainframe product for Claims and enrollment processing and use teh same system to bring teh attributes to PEGA System through API’s.
• Working wif REST API keys and consuming them to teh new system enhancements.
• Involves in Defining teh user stories and acceptance criteria to better understanding to all teh team members.
• Giving an appropriate guidance to teh Dev team to design teh system for teh user’s ecofriendly based on discussion held wif Business unit and giving complete information, making easy way to access all teh departments.
• Data Governance handled for all Providers, member plan benefits, claims data. Maintained Data consistency from Legacy system to newly implemented system.
• Working closely wif Manager, Product Owner and Stake holders to gather all teh requirements and putting them all into teh technical way to pass to teh Dev team to understand in easy to develop teh system.
• Working closely wif Business heads to get all teh business requirements.
• Analyzing all teh fields to insert teh CPT and ICD codes and their description to enhance teh availability of authorization in easy way.
• Discovering teh new ways to improve teh system functionality. Improving teh ways to search for Claims and authorization information.
• Worked wif Facets, Medicare, Medicare advantage plan, Medicaid, MMP (Medicare and Medicaid Plan) and Commercial PPO, HMO and POS Plans.
• Educating teh team members about teh Healthcare rules and how Providers Company will work and how to make our system to receive all teh files from Provider office while billing teh claims.
• Giving teh information and preparing teh system to build teh standalone application by gathering all teh required information to search teh benefits summary for members.
• Working wif EPMO.
• Providing all teh project information to Product Owner on daily basis. Assisting teh team to deliver teh Project on time wif good quality.

Confidential,Vienna, VA

Programmer Analyst

Responsibilities:

• Initiated teh Project to handling all financial reports and their analysis. Pulling teh Financial Reports from Database by Using SQL queries converting them into Excel for further analysis.
• Worked wif Tableau for Financial data analysis and Making analysis visible reports wif Tableau.
• Guiding teh Testing team to write teh UAT testing scenarios against teh Database to check functioning activity.
• Worked wif AWS server (Cloud) where i was responsible for to create some space for teh deployments and remove teh old versions.
• Worked wif Microsoft Suite (Excel, Word, Visio and PowerPoint).
• Document business analysis deliverables such as requirements, workflow diagrams, and testing documentation and halp testing team in understanding teh requirement and come up wif relevant test artifacts.
• Preparing and update noledge repository for teh applications and managing time estimates and fixed deliverables (SOW & Work Order).

Confidential, Bloomington, IL

Project Lead

Responsibilities:

• Experience to Prepare teh Source of Work (SOW) and Protocols.
• Making available Environment for teh New version to Deployed and Checking them wif Claims Database.
• Collecting all teh information for Deployments and Database information in order to design teh Database.
• Worked wif SQL Queries and its executing, Microsoft Suite 2010 (Excel, Word, Visio, Access and PowerPoint) Making Pivot table about teh Claim information and Preparing graphs by using Tableau.
• Responsible to Clean teh Cloud Environment for Future Deployment and Making teh reports about teh Enrollment and Claims database.
• Responsible for all deployments and created unique deployment environment where as in all teh deployments TEMPhas to be performed by one Team (almost 10 Development centers).
• Approached to all level of management to get all teh individual Deployments environment information and make unique environment.
• Working wif all Level of Management leaders and stake holders regarding teh Claims database and its functioning. Updating teh Claims Database Designing and its Functioning.
• Worked wif CPT, HCPCS, ICD9/10 and Modifiers and worked wif Claims adjudication system and analyzing teh claims before releasing teh claims by adjudication process.

Confidential

Senior Process Executive

Responsibilities:

• Worked as Quality Lead. Worked for Billing, Enrollment and Claims Adjudication for Confidential -WellPoint (BCBS) Client.
• Worked for WellPoint Group Systems - Claims processing, Billing and Enrollment process.
• Appreciated and awarded by teh Client for Beyond Expectation Performance and Promoted as a Internal Quality Auditor for Whole Project***.
• Worked for Premium, Self and Group Billing. Enrolling teh Members into New plan and Switch teh Plans during OE and Claims Adjudication as per teh Plan Benefits.
• Solved all teh Queries and stabilized teh Project wif Good Production and Quality as per teh Client target.
• Worked wif State client data CA, CO and NV Clinical data (Medicaid data) Visualization by using Tableau.
• Worked as a Lead for Project, Staffing and Training New hires and Conducting Update sessions, Work Assignment, Collecting teh Production Report and sending teh Collated Report to Management and Client on day to day basis, Used teh same Reports for Quality analysis and making reports as Needed.
• Worked wif OE Forms, HCFA / CMS 1500, UB04 forms, EDI claims (834, 835, 837I and 837P), ICD 9, CPT codes, HCPC codes, Modifiers, HEDIS, Medicare, Medicaid Claims, HMO, PPO, POS, EPO plans and Calculating teh Pre-Existing Information and Worked wif COB / EOB its calculations.
• Worked wif Medicare, Medicaid and Commercial Health Insurance Plans (HMO, PPO, POS plan types).
• Data Governance and Consistency maintained for all Health plans Claims, Member Enrollment data and past enrolled plans, EOB’s data.
• Worked wif Microsoft suite (Excel, Word, Visio, Power Point and Access) and VB Scripting to Create Macros for Daily Enrollment and Reconciliation Production Support, Writing SQL Queries against teh Database to pull teh records and Making Visible reports.
• Worked wif All commercial programs, State and Federal plans.
• Worked wif EPMO.
• Working wif KPI, Improvement towards teh Project Quality, Business and Organization growth. Client Consulting Experience and Primary contact for any Reports and Project information. Hiring, Training and Providing Feed back to teh Management about teh Employee performance and Appraisal Review along wif Manager. Project Planning, Training and Execution to deliver to teh client wif good Quality.

Confidential

Claims Associate

Responsibilities:

• Worked for Claims Adjudication Under teh United Medical Resource (UMR) Branch. Adjudicate teh Claims as per teh Plan Benefits and Coverage Looking over all teh Guidelines as Per CMS, HIPAA and ICD 9 coding guide lines.
• Handle teh Project as a Lead and submitting all teh reports to Management as required.
• Worked wif FACETS, CPT, ICD 9, Modifiers, Revenue Codes, Providers Credentialing, Network Database, HCFA claims and UB-04 Claims, EDI Claims (834, 835, 837I, 837P and 999 etc..), Pre-Existing Claims, Duplicate Claims, Corrected Claims, Secondary Payer Claims. Calculating teh allowed amount after all Deductible, Copay and Coinsurance, Generating teh EOB’s.
• Worked wif Medicare, Medicaid, Commercial Health Insurance Plans (HMO, PPO, POS plan types). Worked wif EPMO and PMO.
• Conducted Training sessions about Healthcare Plan benefits and Guidelines and Various Departments in Healthcare. Committing to noledge development and continuing to educate and share noledge wif clients and team members.
• Handled Data Governance and Consistency for pre-adjudicate claims, adjudicated claims, Referral forms data, authorizations data, member enrollments and plan benefits data, EOB’s data.
• Worked wif Microsoft Suite Products (Excel, Word, Visio, and PowerPoint), Visual Basic (VBA) for Applications, Macros running for Daily iteration work, Data analysis.
• Worked wif SQL to write Queries against teh database to pull teh Claims reports and converting those to Excel sheet for further analysis and Worked wif Tableau for data Visualization.
• Project Management, Production and Quality Management, Work Assignments, working wif all level of Management Leaders and Updating teh Production and Quality Information and Process Improvement. Giving Training to teh Team Members about Healthcare and Plan adjudication tips and major information to be focused on while adjudicating teh Claims.
• Handle all teh New Projects and shared teh Tips and Learning skill about teh Particular Project accomplishment to Team members.

Confidential

Executive

Responsibilities:

• Worked for CHMB client from Provider’s Office, where in used to Bill teh Claims to Various Insurance offices for all type of Specialties by following all teh Healthcare guidelines.
• Worked wif ICD 9, CPT Codes, HCPC System, Modifiers, HCFA / CMS 1500 form, Patient Demographic, Charge Capturing, Good analysis skills to work wif COB / EOB, Payment Posting, Accounts Receivable, Follow up wif Insurance offices about teh Claims status, Rejection Claims, Denial Claims, Familiar wif Clear House rejections, EDI Claims (271, 275, 277, 835, 837I, 837P and 999).
• Good Skills to handle teh Patient’s data base, making reports about all teh Patient’s information, diagnosis information and Treatment information rendered by Physician.
• Handled all EDI data consistent across all teh systems.
• Worked wif Medicare, Medicaid, Commercial Health Insurance Plans (HMO, PPO, and POS plan types).
• Creating Medical Record Number to teh New Patient and updating any change of information to teh Patient database. Worked wif SQL to Update teh Records, making tables, Delete teh Records, Generating ageing reports for AR Process and revenue information.
• Good System setting Experience for all type of Providers to route teh claims to particular insurance offices.
• Good Experience to work wif Microsoft suite Products (Excel, Word, Visio, Power Point and Access), Learned Visual Basics for Application (VBA), Started Using VB Scripting, Analyzing teh Large-scale data wif Excel by using Pivot Tables and making Graphs in Excel.
• Project Management, Trained to New joiners, Production and Quality Management, All teh Clients Revenue Information and debts from Insurance offices.
• Generating Ageing reports in order to work AR process, Based on Ageing reports come to no teh collection needed information (0-30, 30-60, 60-90 days Ageing Reports) and Worked wif 834, 835, 837I and 837P.
• Very good skills in AR process and how to refile teh claims wifin timely filing limit, well versed wif Clearing House Rejections and Insurance office rejections, denials.