Executive Synopsis

• Good Analytical and Logical Skills.
• Proven experience in end-to-end project delivery effort from project initiation to closure.
• Lead various mission critical projects like ICD-9 to ICD-10 conversion, IDMS to DB2 migration, etc. for a major US Healthcare Payer, with high quality and customer satisfaction.
• Experience in Development and Maintenance projects.
• Worked closely with various stakeholders to understand and document Business Requirements, Functional Requirements Design specifications.
• Delivered multiple projects with both on-line and batch functionality using CICS/ADSO Maps for UI, DB2/IDMS/VSAM for Database and COBOL/JCL/Easytrieve for batch processing.
• Worked on other mainframe tools like FILE-AID, ABEND-AID, ISPF, PANVALET, SPUFI, PLATINUM, CA-7, DMLO, OLQ, IDDM, ADSALIVE, DSFORT, SDF II, etc.
• Implemented multiple best practices by introducing various process documents and checklists to improve delivery excellence.
• Proven experience in all stages of Software Development Life Cycle. Good understanding of Waterfall methodology.
• Proven experience in coaching, mentoring teams and evaluation of team members to achieve project goals/objectives.
• Quick Learning aptitude, excellent communication and organizational skills
• Focus on quality and drive for excellence

Core Competencies

• Strong skills in Mainframe Technologies COBOL, JCL, IDMS, DB2, CICS, etc. .
• Incident/Problem Management tools CA Service Desk manager .
• Extensive knowledge on processes and procedures followed in Healthcare domain
• Extensively worked on preparation of design documents, workflows, development, testing, production support and maintenance of projects
• Working experience on the most crucial and high visible proposal for converting CA IDMS database to IBM DB2. This involved in evolving the methodology right from scratch along with estimates.

Assignments

Confidential

Software Used Mainframe: JCL, COBOL, Datacom, IDEAL, CICS, VSAM, FILE-MANAGER, IBM MVS, ISPF, ABEND-AID, XPEDITER

Project Description

• The Centers for Medicare and Medicaid Services Confidential expanded its authority to collect and use encounter data for risk adjustment and other purposes.
• Under the Medicare Advantage Confidential Rule amendment, Confidential can require Confidential organizations to submit encounter data that characterize s the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician or other practitioner, as well as the functional limitations of enrollees.
• CMS intends to use this data to adjust the monthly payments it makes to MA organizations under its Hierarchical Condition Category Confidential risk adjustment payment methodology, which determines the annual risk scores of MA plan enrollees. programs.

Bussiness Needs

• Confidential implemented managed care in Confidential and has been collecting encounter data for over 10 years. Starting in 2000, data were collected in a state-developed proprietary format in Confidential, the state began requiring plans to submit claims in the 837 HIPAA electronic transaction format. This format brought better standardization to encounter data reporting, making it more complete and easier to identify errors.
• The state uses service-based enhancement payments to plans that have extra payments triggered by meeting thresholds for the submission of certain encounter data records. This provides additional incentive for Confidential to report data to the state in a timely fashion.
• Confidential is required to report their data monthly or choose to report more frequently. When the state first started requiring encounter data collection, some plans proved more successful than others in submitting the data. Confidential maintained the required data in their own systems and so had to create a claim-like transaction in-house before they submitted.
• Report amounts that Confidential pay to providers unless the servicing provider was paid under a capitation agreement.
• The encounter data sent to Confidential continues to drive the risk scores for the members and therefore the capitation paid to the Providers.
• From a broader perspective, if the overall encounter data submitted is incomplete, Confidential will not have an accurate picture of the range and intensity of services provided to MA members, which could lead to a reduction in reimbursement across the industry.
• Lastly, encounter data can be utilized for other reasons such as HEDIS, 5 Star, and Medical Management purposes.
• Failure to submit accurate, complete data in the required format prevents Confidential from storing and utilizing the data, which can impact member quality of care and Confidential quality scores

Provided Solution

• Designed an automated process with the ability in the Premier Claims system to extract the finalized claims distinguished by the types of services that includes the below types of claims
• Professional,
• Institutional and
• DME
• This extraction process will to be automated and to be performed in regular intervals as mandated by CMS requirement. The extract file layout and format will be determined in a later stage during the design phase.
• The extract file should contain all finalized claims for a particular duration of period for which the data should be sent to CMS
• The Premier system should be able to create X12 837 files for Professional, Institutional and DME claims that should be in 5010 format and should have passed all the Edifecs edits. Refer to the Database design for 837 Claims section for the database design.
• Designed a new database that stores the cleansed data is subject to change. Ongoing discussion with the Risk Adjustment Services team.

Responsibilities

• Interact with stakeholders /Business on daily basis to elicit the requirements
• Create Business requirement document and get signed off from stakeholders
• Review Create Business requirement document created by team members and provide comments to make sure all requirements are captured
• Conduct status call on daily basis to update the progress in the project
• Project estimations and planning.
• Helping the team during build process and review of components.
• Ensure smooth testing of components from test creation/documentation to execution.
• Understanding business requirements in consultation with the business user/client/onsite and baseline the requirements.
• Schedule/Attend meetings with Business users and other application areas.
• Preparation and review of high level and low lever design documents.
• Coordination with offshore teams during build/coding and resolve any technical/business issues.
• Review of components/processes/test results/ final deliverables
• Documentation of processes/changes to existing system.

Confidential

Project Lead

Software Used Mainframe: JCL, COBOL, DB2, PLATINUM, CICS, EASYTRIEVE, VSAM, FILE-AID, IBM MVS, ISPF, ABEND-AID, XPEDITER

Project Description

The Confidential Administration and Finance System developed by Confidential which is now taken over by HP allows insurers, employer groups and health care organizations to administer health maintenance organizations HMO , preferred provider organizations PPO , indemnity and a variety of hybrid managed care programs.

Bussiness Needs

Poor white space management and Blank Page reduction in the use of Xerox Printers leads to high cost.

Maintenance of company Logo required manual efforts of creating a CSV file each time the logo is changed.

More Customer friendly EOBs were required that had all information available at a glance at one place, thereby boosting member satisfaction, retention and referral rates at lowest delivery cost.

Provided Solution

• Utilize HP Exstream software convert EOB and EOR printing on Confidential printers
• Built the Data stream required to process the EOB and EOR printing on Exstream platform.
• Extreme software draws data from customer database and files to incorporates colorful icons and images, tables and charts to communicate information better.
• Additional features and flexibility of Exstream Platform allows current and future projects to be implemented in a timelier and cost effective manner.

Business Benefits

• Capability of providing historical Information of checks ISSUED and VOIDED executed prior to POS PAY Implementation.
• Flexibility of Re-transmission of Pos Pay file in case of Transmission Failures or Delays.
• Capable enough to adapt new changes in TRASMSSION SETUP demanded by Banks within very minimal time span.

Responsibilities

• Ensure project milestones are met
• Track project metrics and provide project status reporting to leadership.
• Establish and facilitate regular project team meetings.
• Creation of various project documents like V S, SRS, SAD, Issue Logs, etc..
• Project estimations and planning.
• Helping the team during build process and review of components.
• Ensure smooth testing of components from test creation/documentation to execution.
• Understanding business requirements in consultation with the business user/client/onsite and baseline the requirements.
• Schedule/Attend meetings with Business users and other application areas.
• Preparation and review of high level and low lever design documents.
• Coordination with offshore teams during build/coding and resolve any technical/business issues.
• Review of components/processes/test results/ final deliverables
• Documentation of processes/changes to existing system.

Confidential

Project Lead

Software Used Mainframe: JCL, COBOL, IDMS, ADS/O, DB2, CICS, EASYTRIEVE, VSAM, FILE-AID, IBM OS/390, MVS, ISPF, IDDM, OLQ, DML/O, ABEND-AID, XPEDITER, ADSALIVE

Project Description

• Confidential is state-of-the-art reimbursement system. Confidential is an accounting application that controls provider reimbursement for managed care products through: a provider capitation payment, b control of claims payment - pay, encounter, suspend or reject, c claims expensing, and d reconciliation settlement .
• It is one of Legacy systems in Confidential which was mostly in maintenance mode for years. Because of increase in Confidential business and Service Fund being key system in maintaining Confidential membership to reimburse gated providers, Confidential. is focusing on modernization of this system. To achieve this, number of enhancements has been made to the system.
• Due to Health Care Reform and several enterprise-wide initiatives to capture member-level capitation and other member-level financial data, it is necessary to enable Service Fund to record Member and/or Member-Claim level detail for manual adjustments wherever possible.
• The 'Manual Adjustment at Member Claim Level' project consists of enhancements to Service Fund in order to allow manual adjustments of contract funds to be captured at the Member and/or Member-Claim level when that level of data granularity is available. Currently all manual adjustments are done at the Fund level only.
• These enhancements will impact the Service Fund Adjustments screen, automated data feeds into the fund adjustment process, and associated output reports/data-files

Responsibilities

• Leading the team.
• Providing support to the team in technical aspects.
• Knowledge transition on IDMS to new team members.
• Ensure project milestones are met
• Establish and facilitate regular project team meetings.
• Helping the team during build process and review of components.
• Ensure smooth testing of components from test creation/documentation to execution.
• Understanding business requirements in consultation with the business user/client/onsite and baseline the requirements.
• Schedule/Attend meetings with onsite team and other application areas.
• Preparation and review of low level design documents.
• Review of components/processes/test results/ final deliverables
• Documentation of processes/changes to existing system.

Confidential

Senior Developer

Software Used Mainframe: JCL, COBOL, IDMS, ADS/O, DB2, CICS, EASYTRIEVE, VSAM, FILE-AID, IBM OS/390, MVS, ISPF, IDDM, OLQ, DML/O, ABEND-AID, XPEDITER, ADSALIVE

Project Description

Implement various enhancements in application to address new business needs, improve reporting capabilities, improve user experience and provider experience, make compliance related enhancements and prepare for future expansion of application scope.

Responsibilities

• Track project status, manage and escalate project issues and risks as appropriate.
• Ensure project milestones are met and determine mitigation if risk of not meeting milestones exist.
• Track project metrics and provide project status reporting to leadership and customer.
• Creation of various project documents like V S, SRS, SAD, Issue Logs, etc..
• Helping the team during build process and review of components.
• Ensure smooth testing of components from test creation/documentation to execution.
• Post production operations support and warranty support.
• I hereby declare that the information that I have furnished is authentic, and true to the best of my knowledge.