SUMMARY:

• Dynamic leader of Technical team with 11+ Years of technical and business experience in Healthcare industry managing critical and complex projects using various technologies with 2 years in Pega BPM applications and 9+ Years in Mainframe and Java and other web - based technologies like SOAP etc.
• Strong technical, business, database skills combined with good communication, innovative ideas and leadership skills.
• Strong knowledge in Health care domain and Business Process Management tool Pega PRPC 7 and other tools like Rational Functional tester, Java script, .Net and other automation work done on Mainframe technology like JCL, REXX, VSAM.
• Knowledge on Pega PRPC concepts like Case life cycle design, branching, Rule resolution, Case Life Cycle Design, Case workflow, Data Modeling, Activities, Data transform etc.
• Knowledge on designing application interface and UI design using Harness, Layouts and Sections and Styling using Skins, Mixin and Formats.
• Worked on managing security and access related concepts like creating and managing Access Groups, Operators, Work Basket and Privileges etc.
• Knowledge on Application debugging using Clipboard, Tracer and System and Data performance management using SMA, PLA, Database Trace and Performance Profiler etc.
• Knowledge on Pega CPM (Customer Process Manager) along with HCIF Framework (Healthcare Industry Foundation) and Pega CMA (Care Management Application)
• Experience in Databases like Teradata, IBM DB2 and Oracle SQL and worked on developing query language in respective databases.
• Project management experience including resource planning, reporting to Clients and other stakeholders and managing the timelines TEMPeffectively.
• Has worked on the end to end processing in a healthcare system starting from building the benefits, Enrollment and billing, Claims processing, Explanation of Benefits, ITS processing and Cash disbursement.
• Worked on rational tools like Rational Quality manager (Waterfall model) and Atlassian JIRA (Agile - Scrum model) to generate all the artifacts like test plan, test scripts and defects etc.
• Expertise in Creating/Executing/Troubleshooting automation test scripts generated from test cases.
• Extensive experience on Analysis, Testing and Implementation of Mainframe applications using COBOL, DB2, JCL, TSO/ISPF, VSAM, SPUFI and QMF, .Net and web-based applications.
• Experienced with various types of testing like GUI testing, Web testing, Regression testing, User Acceptance Testing (UAT), Functional Testing, System Testing, Integration Testing, End to End Testing, Unit Testing, Black Box Testing, White Box Testing, Documentation and Reporting.
• Worked on Teradata .net framework to generate reports using ANSI SQL queries based on the requirements to get from Enterprise Database.
• Extensively worked on DB2 and .net front end validation for different GUI systems to retrieve data and report validation.
• Interested and looking forward in recent technologies like Cloud computing, Robotics automation.

TECHNICAL SKILLS:

Programming LANGUAGES: Pega PRPC 7, Java, Web Services (SOAP), JSP, PEGA CPM, HCIF.

Scripting Languages: Java scripting and VB Scripting and .Net, XML.

Mainframe Technologies: JCL, COBOL, VSAM, DB2, REXX, ISPF, SPUFI

Database Technologies: Teradata, DB2 and SQL, Apache Tomcat.

Project Methodologies: Waterfall and Agile-Scrum.

Rational SUITE: Rational Quality Manager, Requisite PRO, Rational Functional Tester, Rational Clear Quest.

PROFESSIONAL EXPERIENCE:

Confidential, Richmond, VA

Responsibilities:

• Worked on Case life cycle design and managing the transitions between different stages using Decision tools like Decision tables, Decision trees etc. and other advanced tools using Smart shapes and implemented different functionalities like Duplicate case search, Temporary case management and Persisting of temporary cases etc.
• Worked on Agile methodology to develop the application changes in Agile mode to release the changes on Demand.
• Worked on process flows, manage routing using Work baskets, Work groups etc.
• Generate Report definitions, Charts by applying the concepts of Pega Database BLOB and Pega Database table and Database records and Class joins.
• Interact with other internal systems using SOA layer communications.
• Managed the portals for different level of users including the report definitions and task routing.
• Worked on application User Interface (UI) design using Sections, Harness and flow actions etc.
• Implementation of processing features like Expressions, Data Transforms, Activities etc.
• Used different application debugging tools like Clipboard, Tracer etc.
• Monitored system and database performance using PLA, SMA, PAL, Database Tracer etc.
• Followed Pega Standards and PEGA Guardrails while developing and implementing applications.
• Worked on organizing and managing Production rulesets for Delegated rules in production environment.
• Worked on creating and managing test cases and test case suites to be able to do Unit testing, regression testing etc. for the changes done on a Sprint/release.
• Sending and communicating the Work status reports and communicate TEMPeffectively with all Stakeholders.

Confidential, Richmond, VA

Responsibilities:

• Provided estimates on work efforts and acted as Subject matter expert in different areas like Benefits administration, Evidence of Coverage system, Utilization management, Claims adjudication and HIPPA 270/271 and 276/277 transactions.
• Worked on different migration project like
• ICD 9 to ICD10 conversion which involved major changes in terms of benefit administration and Claims processing for any health care system. Covered all the aspects of a health care system during dis change to make sure that system is in compliance with ICD10 Procedure and diagnosis codes.
• North Employer Pricing migration to WellPoint group system 2.0 and the corresponding claims interaction with the new Claim Pricing system and Claims adjudication and validation process.
• Benefits accumulator changes to be loaded in ACCUM ODS (Operational Data Store - a centralized benefit storage system) from source system and the interaction with the ACCUM HUB.
• VB6 to .net conversion project which involved changes in the technical aspects for an entire Subsystem for Benefits administration and the interfaces that interact with different databases in the system.
• Claims interaction with outside systems like ACCUM HUB ODS and the different rules in Claims adjudication
• Claims interaction with XTEN servers like McKesson and interfaces that will interact between source system and McKesson servers
• Interaction of Claims and for CDHP members with LITES Server.
• HIX (Health Interchange) migration testing for and claims processing including forward sync and backward sync.
• Worked on interaction on interfaces with external vendors for Claims and processing like AIM (Utilization management system for services like Radiology, genetic testing etc.), Pharmacy vendors like CVS, ESI Direct etc. and Vision vendors like VSP etc.
• Worked on projects that deals with many Federal (Healthcare reform, Mental Health mandate etc.) and State specific mandates (Connecticut Mental health parity mandate, Hearing aids mandate etc.) to embed those mandates into the current health care system in terms of and Claims adjudication.
• Interaction with business and other stakeholders in terms of analyzing requirements, developing test plans, test cases and test scripts in order to completely test a given project
• Coordinated between different subsystems for a Project through the life cycle of a project starting from Requirements through implementation.
• Worked on to analyze, develop and execute test scripts for a project or work effort.
• Responsible for presenting UAT’s with Business people and Analysts.
• Loaded the data for the Resolution, Adjustment/void functionality/ Mass Adjustment functionality through the backend level by writing the Stored Procedures, Functions Inner/Outer Joins, and Loops with the Respective tables.
• Designed and developed multiple automation tools in Rational Functional tester, JCL and REXX that reduced the manual work efforts and save costs.
• Design the Test plan and Prepared and Maintained Test plan and Test cases using Rational Test Management Tool (RTM).
• Worked on report generation and validation that will feed System level data to different Enterprise level systems like Teradata, ABACUS etc.
• Worked on GHI file processing for, Electronics enrollment and other Medicare and Medicaid related projects.
• Worked on validation of EOBs and other reporting like Evidence of Coverage, ID card printing etc.
• Worked extensively on all X12 transactions -837(P, D and I), 835-Remitance advice, 270/271- Member eligibility and response, 276/277-Claims status and response.
• Worked on different reporting and Stakeholders meeting like status reporting, SLA reporting and other reporting specific to different projects and other Walk through meetings.

Confidential

Team Lead

Responsibilities:

• Worked on enrollment processing and Claims adjudication processing including ITS Host and ITS Home plan processing.
• Handled ITS (Inter Teleprocessing System) requests from Onsite and other Subsystems.
• Worked on many new business projects and validated the claims adjudication over the new business rules.
• Worked on claims adjudication interface with other vendor systems like XTEN,
• Experience in handling error resolution while validating claims adjudications.
• Handful experience in PLASM Coding of benefits using COBOL and other mainframe modules.
• Excellent experience in resolving errors in ITS SF file validation.
• Developed different automation tools in REXX which reduced efforts and automated the claims testing and enrollment process.
• Responsible in preventing the deliverables to the customers.
• Responsible for the TEMPeffective communication between the team and other subsystems. Provided direction to the team when the situation demands.
• Trained new joiners over the system and other healthcare related topics and make them productive.
• Worked on different rational tools like Rational Quality manager, Rational Requisite pro, Rational Clear Quest and Rational Functional tester etc.