SUMMARY

• Bit more than seven years of extensive experience in Information Technology with special emphasis on Design and Development of Data Warehousing using Informatica PowerCenter in Health care
• Expertise Knowledge of UB04 and HCFA CMS 1500 forms
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Experience designing and developing SQL statements and queries for Oracle Sybase and SQL Server 2000 database.
• Understanding of CPT, HCPC, and ICD - 9 codes
• Proposed strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.Facilitate HIPAA integration and applied ANSI ASC X12 standards for 837 (P, I, D), 270/271, 276/277, 278, and 835 transactions.
• Strong expertise in Relational data base systems like Oracle, SQL Server, and MS Access.
• Experience working on Health care Reform Projects such as Health Insurance Exchange (HIX), ICD 10 Remediation and HIPAA 5010 Implementation.
• Strong Knowledge on claim processing and EDI transactions i.e. Claims Inquiry and Response (276/277), Receipt and Verification of claim forms (820, 834, 837), Claim Payment and advice (835), Eligibility Inquiry and Response (270/271), Certification Request and Response ( 13 ), Benefit Enrollment (834), Order and Payment Remittance (820), Invoice (810).
• Experience in the health care payer value chain across different segment of Health care, Health Insurance Exchange (HIX) and Government reforms.
• Performed gap analysis between the 4010 and 5010.Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Extensive experience in modeling for OLAP & OLTP systems
• Working knowledge on dimensional modeling, Ralph Kimball Methodology, Bill Inmon Methodology, Logical Modeling, Physical Modeling, Dimensional Data Modeling, master data management, data migration, staging, cleansing and mining features for data warehouses.
• Experience working in Oracle, SQL Server-SSIS, and Teradata and DB2 environments.
• Handled Electronic Medical Records (EMR) and Electronic Health Records (EHR) to prepare documentation for business requirements and process flows.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Extensive experience in configuring data mapping between different Databases.
• Proficient in developing Use Case Model, Analysis Model, Design Model, Implementation Model, Use Case Diagrams, Behavior Diagrams (Sequence diagrams, Collaboration diagrams, State chart diagrams, Activity diagrams), Class Diagrams based on UML using Rational Rose
• In depth knowledge of CMS, EDPS, and RAPS
• Knowledge and experience with Data migration, Data mapping, ETL, and reporting process.
• Experienced with processing medical claims- ICD-9, UB04, HCFA 1500, CPT
• Proficient in Unit Test Plans (UTP), Integrated Test Plans (ITP) Extensive experience in User Acceptance Testing (UAT).

TECHNICAL SKILLS

EDI Transactions: X12, 820, 834, 835, 837 transaction sets

Methodologies: Agile Modeling, Scrum, SDLC model, Waterfall model, Use Cases, JAD

Master Data: IBM InfoSphere MDM 8.5, 9, 10 and 11, 11.3

Database Tools: SQL*Plus, SQL*Loader, MySQL, Toad

ETL Tools: IBM InfoSphere DataStage, Informatica PowerCenter, and MicrosoftSSIS

Databases: Oracle, MySQL 5.0, IBM DB2 9, MS SQL Server 2008/2012

Other Tools: Clear Case, MS SharePoint, Documentum, and Filenet

Languages: UML, C, C++, HTML, Java, SQL, PL/SQL, ASP.NET

Business Tools: MS Visio, MS Project, MS Access, MS Office Suite, Visual Paradigm, Doors, Erwin Data Modeler 4x, Business Object (Crystal Reports), MicroStrategy.

PROFESSIONAL EXPERIENCE

Confidential, Oakland, CA

Business Analyst

Responsibilities:

• Wrote requirements to implement the new 834 changes recommended by the Affordable Act and by the partnership with the Health Insurance Exchange (HIX).
• Verified monthly eligibility HMO / PPO Insurance, AND Medicare HMO.
• Involved in enhancements and maintenance activities of the data warehouse including tuning, modifying of stored procedures for code enhancements.
• Facilitated Scrum Ceremonies like Sprint Planning Meetings, Daily Standup Meeting, Sprint Review Meetings, and Sprint Retrospective Meetings.
• Understanding the mappings and logics built in Informatica to extract and load the data from Oracle ERP (OLTP) system to the Data warehouse (OLAP) system.
• Created SQL queries to pull out data and metrics from the database and assisted in creating the Physical database for IBM MDM and the Data Mart.
• Used Toad to run SQL queries to get the useful information from database.
• Performed requirements gathering, business process mapping and re-engineering as a part of health exchange readiness efforts for leading public health plan entering state HIX market
• Act as a liaison between medical insurance and/or pharmacy benefit providers and physician office to aid in the process of obtaining a prior authorization
• Established HIPAA field validation procedure and executed formatting and mapping successfully.
• Support the development and implementation of Affordable Care Act (ACA) and Health Insurance Exchange (HIX)
• Managed onshore and offshore scrum team workflow and capacity to ensure delivery of features in scope and on time
• Create table structures in IBM Cognos Framework Manager from different sources (Oracle, SQL)
• Responsible for verifying of data integration/migration from various distributors systems into the Data Warehouse environment and maintaining the Informatica Repository.
• Involved in Analyzing / building Teradata EDW using Teradata ETL utilities and Informatica
• Assist with pharmacy benefit management services for Medicaid, Medicare and commercial health plans.
• Create and maintain data model/architecture standards, including master data management (MDM)
• Conducted data mapping and data migration using SQL queries and MS Office tools.
• Process medical claims- UB04, UB92, HCFA 1500
• Involved in requirement gathering and testing of consumer web portal for the enrollment of Medicare members.
• Involved in dimensional database design for the data warehouse. Created logical and physical data models using Erwin.
• Involved in complete SDLC including architecture, analysis, design, development, testing, implementation & maintenance of application software in the Enterprise Data Warehouse with production support.
• Design and development of EDPS (Encounter Data Processing System) produce to submit and reconcile encounters to CMS for Medicare clients
• Implemented HIPAA/EDI transactions like 820,834,835,837.
• Extensive success in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) in an SOA environment.
• Audit HCFA 1500 forms assuring completion based on carrier compliance. Follow up with insurance carrier on status of outstanding claims.
• Involved in development phase meetings for business analysis and requirements gathering for the Common Claim Layout (CCL).
• Serve as a subject matter expert within the organization for all procedural and diagnosis code sets, including but not limited to: ICD-9, ICD-10, DRG, CPT, and HCPCS.
• Designed and developed applications to convert various paper-based medical records to HIPAA compliant, secure EDI transactions.
• Lead scrum, sprint planning and sprint retrospective meetings with developers, quality analysts and business analysts.
• Create and process HCFA 1500 forms for insurance clients

Confidential, NE

Business Analyst

Responsibilities:

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Created data models for relational schemas (OLTP) and dimensional schemas (OLAP) with proper normalization and denormalization techniques
• Involved in Analyzing / building Teradata EDW using Teradata ETL utilities and Informatica.
• Worked in a Scrum team environment and participate in backlog review and Sprint planning sessions, following agile methodology.
• Performed requirements gathering, business process mapping and re-engineering as a part of health exchange readiness efforts for leading public health plan entering state HIX market.
• Involved in health insurance exchange (HIX) market strategy, requirements, and regulatory approach.
• Worked with the clients, business analysts to design develop and enhance Data Warehouse models, scripts, procedures and metadata for relational databases.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Working closely with business users for to define UAT strategies and data validation.
• Developed complex program models using SQL Visual Studio 2008 to extract data from multiple data sources to load data marts, enterprise reporting systems and dashboards.
• Used Teradata Data Mover to copy data and objects such as tables and statistics from one system to another.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Created scripts to create new tables, views, materialized views and queries using TOAD
• Used project related tools including Cognos, MS Visio, MS Project.
• Converted existing PL-SQL procedures to ETL code to remove some of the heavy ETL processing from RDBMS to a separate Informatica server.
• Monitored the compliance mapping of transactions to the EDI transactions standards ANSI -X12.
• Worked on Member and claim domain applications, for HIX (Health insurance Exchange) Project.
• Research CPT, HCPCs and ICD-9 codes for erroneous billing habits in provider's history
• Reviewed medical records to determine correct ICD-9 and CPT codes within several specialties including neurology, general surgery, urology, and internal medicine.
• Designed and developed project document templates based on SDLC methodology
• Working with Medicare, Medicaid, PPO, HMO, & Workers Comp accounts.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.
• Work closely with the Prescribing Physicians and Pharmacy Benefit Managers to maximize compliance and positive therapy outcomes.
• Developed/modified the PL-SQL procedures for implementing complex business rules.
• Validating the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Involved in resolving and documenting issues related to these EDI transactions including 837 transactions using Test Director.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Participated in daily Scrum meetings with Project Manager, Development Team and QA Team and calculated LOE and fitted it into the Work-Breakdown-Structure
• Recommend tactic to implement HIPAA 4010 (EDI X12 837,834,278,270) in the new System
• Configured the Data mapping between Oracle and SQL Server 2008.
• Developed multiple project plans to implement new controls to track and account for all EDI claims.
• Worked on the internal healthcare reform and on the implementation of the Affordable Care Act (ACA).

Confidential, Louisville, KY

Business Analyst

Responsibilities:

• Analyzed existing reports and defined business requirements and business process flows.
• Encounter submission and error reconciliation - Centers for Medicaid and Medicare Services(CMS) Encounter data processing system (EDPS) and Risk Adjustment Processing System (RAPS)
• Request Authorization for all MediConnect Residents and HMO admission.
• Educated and reinforced scrum methodology and agile framework to team members and key stakeholders.
• Gathered business requirements by conducting JRP sessions and used the same to prepare the business Requirements and Functional Specifications Documents.
• Manage Centrally Managed Suppliers List for the MDM Team by keeping Category Managers, Payments Terms, Sub Categories, and PPRs up to date to match updated contracts.
• Run and Manage MDM Supplier and Item Metrics through weekly Oracle reports and Represent Supplier Management for the Adhoc Power User Group (PUG).
• Configured and managed data sources for MS-SQL,DB2and Teradata databases.
• Developed an implementation plan for Partners for EDI x12 transactions such as 834, 835,837,270 and 271.
• Processed and analyzed HCFA 1500 and UB-92 claim forms.
• Handled PPO, HMO, BCBS, Medicare, DME, dental and vision claim forms. Handled TPL-assignment of legal obligation of third parties (i.e. individuals, private ins., workers comp, probate-estate recoveries, court judgments or settlements from liability insurer, long-term care ins., entities or programs) to pay all or part of medical expenses.
• Verified eligibility, coordination of benefits, EOB and handled class action lawsuit settlement claims.
• Manage large volumes of pharmacy benefit corporate claims.
• HIPAA related EDI development for 837, EDPS, 835 and other EDI processes using Pervasive EDI translator.
• Perform data mining, data validation, and create tables within Monarch Pro, Excel, and Access.
• Produced various data mapping specifications to outline data movements in a target-to-source format.
• Analyzed the Affordable Care Act and other Federal and state regulations pertaining to the creation and implementation of a Health Insurance Exchange (HIX).
• Performed Data extraction, Data Migration and Data conversion using ETL tools from application front-end with Oracle databases and data warehouse.
• Constructed compliance risk assessment for plan setup and claims to be in accordance with ACA.
• Create and update new and existing maps for EDPS implementation.
• Helped developers with the following list of HIPAA-EDI Transaction Code sets: (837, 835, 270/271, and 276/277).
• Developed the test scripts using SQL for the unit testing.
• Responsible for testing new state and federal mandates that may potentially impact the EDI file processing.
• Analyze, design, implement, and evaluate business requirements for various projects from initial phase to final implementation, assuring requirements meet standards in Agile/Scrum environment.
• Created Metadata manager Service, Reporting Service and Reference Table Manager Service in PowerCenter Admin Console to effectively use Metadata Manager.
• Working knowledge of regulatory requirements (HIPAA, 21 CFR Part 11) and audits.
• Utilized corporation developed Agile SDLC methodology. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
• Design and develop new database objects like tables, procedures, functions, indexes, and views using Oracle and SQL Server.
• Used the Waterfall model and was involved in all phases of SDLC
• Involved in Health Insurance Exchange (HIX) market strategy, requirements, and regulatory approach.