SUMMARY:

• Seventeen years of extensive healthcare payer domain knowledge, deep understanding of all main aspects in healthcare insurance industry, familiar with both healthcare payer and TPA business, specializing in system integration between payer and third - party systems through APIs and web services;
• Deep knowledge on HealthRules Payor implementation/migration, including commercial insurance plans as well as the government programs like Medicare and Medicaid. Extensive experience with various healthcare payer systems used in the industry such as LuminX, Eldorado, EZ-CAP, MediWeb;
• Thorough understanding of the end-to-end healthcare insurance claim processing lifecycle and benefit plans, deep knowledge of the claim adjudication process and claim financial. Broad knowledge about specific processes such as repricing, claim editing, authorization, Coordination of Benefit, DRG grouping;
• Expert knowledge to integrate/interpret HIPAA X12 transaction sets used in healthcare industry such as 834, 837P/I/D, 835, 277CA, 999/997, 270/271, 276/277, NCPDP. Familiar with validation process using ClarEDI and Optum Testing Service. Working knowledge of other non-X12 EDI format such as NSF, ITS, CMS required EDS and RAPS format, as well as other customized format. Previous experience of coding/implementing EDI transactions with trading partners from scratch;
• Comprehensive healthcare data conversion and data analysis experience with MS SQL Server, Oracle, MySQL. Familiar with OLTP and Data Warehouse. Specializing in Healthcare data mapping between various systems. Excellent working experience writing SQL query and stored procedure. Familiar with database tools like MS Management Studio, Oracle SQL Developer, ERWin;
• Solid IT background. More than 12 years of programming experience using VB.Net, Java, C#, Flex, with various backend databases. Working knowledge of Visual Studio, Eclipse, IntelliJ, TFS, Perforce. Familiar with both Windows and Linux environments. Previous system and network administration experience in Windows Server domain;
• Strong testing experience. Creating test cases and using various tools and system functions to test the benefit plans or other business processes. Extensive experience with data analysis and scenario deep diving. Working knowledge using applications like JIRA, SalesForce, HP Quality Center;
• Deeply involved in ICD-10 conversion, good understanding of all code sets used in healthcare industry such as ICD-9/ICD-10 diagnosis codes, ICD-9/ICD-10 procedure codes, CPT-4, HCPCS, Revenue Codes, ADA Codes, DRG codes, CARC/RARC codes;
• Proven solution architect experience to design cross platform solutions or crafting work around for system limitations to meet client requirements and suggest best practice, including EDI transactions, provider/member matching, data cleansing, network routing, enrollment audit, financial analysis, various healthcare and non-healthcare reporting. Working knowledge of project implementation, resource management and cost/effort estimation.
• Thorough understanding of various SDLC models. Latest working experience has been mainly with Agile/Scrum model. Performed the Scrum Master role in the recent project when no dedicated Scrum Master was assigned;
• Excellent customer facing ability, extensive technical and business consulting experience with the recent four years mainly onsite, outstanding presenting and communication skills;
• Deeply involved in various typed of BPO process in previous job with both US based teams and off-shore teams in various countries. Familiar remote team communications and management on both healthcare business and IT projects;
• Strong self-starter with good team playing skills. Experience fast paced multi-tasking environment. Eagerly to adaptive to new process, technologies that can make the industry better and more effective.

TECHNICAL SKILLS:

Operating Systems: MS Windows, Linux

Programming Languages: VB.Net, Java, C#, VB6, Flex

Database: MS SQL Server, Oracle, MySQL, MS Access

Applications: MS Visual Studio, MS Management Studio, FrameworkEDI, MS TFS, Eclipse, Intellij, Perforce, Weblogic Server, iWay Server, Soap UI, SQL Developer, Toad, MS Office, MS SharePoint, JIRA, SalesForce, HP Quality Center

PROFESSIONAL EXPERIENCE:

Lead Integration Consultant

Confidential

• Lead onsite and remote technical discussion with multiple clients, gather requirements and define work flow for interfaces in various business areas;
• Set up Integration milestones and prepare SOW with PM and Architects;
• Perform integration discussion with clients/trading partners and suggest best practice;
• Lead various migration/integration mapping among data warehouses, EDI transactions and third party/client custom data format, and web services.
• Direct fellow analysts to create BRDs, mapping documents for various interfaces;
• Define and clarify integration team to create the integration structure to meet various clients’ business needs
• Provide guidance to the integration team on interface development;
• Research and direct integration team on resolving issues in various development phases and production.
• Define testing strategy with the testing team and creating test plans;
• Acting as system and integration expert to resolve integration issues;
• Mentor fellow onshore and offshore team members;

Senior Technical Business Consultant

Confidential

• Client engagement for claim adjudication and care manager system implementation/migration. Perform project discovery session, evaluate working efforts, work with PMs to create SOWs;
• Gather business requirements, provide guidance and suggestion for project flows, clarify issues with client SMEs, support client configuration and integration teams;
• Perform gap analysis, design integration solutions or workaround and present them to the client if needed, prepare JIRA/SalesForce/HP QC tickets for enhancement requests/test results;
• Review and debug the integration layer and custom codes for issues, design custom solutions to work around integration layer limitations;
• Perform data mapping for custom solutions, prepare and execute testing to validate the product functionalities and custom solutions;
• Work with PM to decide priorities and delivery timelines, meet with professional service development team to understand business requirements and suggest approaches/solutions;
• Work with client trading partners and other third parties to support and implement the interfacing of the system;
• Provide production support and ad-hoc data analysis request in Oracle OLTP and SQL Data Warehouse;
• Review product enhancement request with the engineering team, help clarify the business logic and system behavior for new releases;
• Provide healthcare domain and EDI expertise to all teams. Mentor fellow consultants and developers to understand healthcare business and technical requirements

Confidential

• Implementing HealthRules Payor to support Medicare and Medicaid. Perform estimates for technical efforts of the project.;
• Various X12 and non-X12 EDI interfacing for enrollment, claims, encounter data, payments, accumulator exchange with trading partners like CVS, Emdeon, Beacon Health, etc.;
• Design solutions to support Medicare reporting for EDS and RAPS. Communicating with CMS for testing. Build custom application to load CMS reports for additional analysis and reporting;
• Debug the current Java integration layer issues implemented in Linux environment. Perform code review and QA for Junior Developers. Lead daily Scrum stand-up;
• Performing data analysis in Oracle OLTP and SQL Data Warehouse. Production support for interface and data related issues.;
• Perform detailed analysis and provide analysis reports for customer management team. Support customer user acceptance testing

Confidential

• Implementing HealthRules Payor to support commercial insurance plans, BCBSA ITS, and BUPA. Provide estimates for technical efforts;
• Various X12 and non-X12 EDI interfacing for enrollment, claims, repricing and COB claim processing, payments, accumulator exchange with trading partners like IBC, BCBSA, BUPA;
• Performing code review to help improving the integration layer. Design technical solutions for customer requirements and creating corresponding JIRA or SalesForce tickets. Perform data mapping. Present solutions to the customer teams;
• Meeting with development team to help understand the requirements, creating test cases and perform integration testing;
• Work with customer Biztalk and QA team to support integration and user acceptance testing;
• Data analysis in Oracle OLTP and SQL Data Warehouse. Attending routing technical meetings to report process and issues

Senior .Net Developer

Confidential

• Implementing automated business reporting tools to perform financial and trend analysis for hospitals;
• Perform ad hoc analysis for trending outliers and other custom requests, creating stored procedures for routinely used analysis tasks;
• Managing system database, creating database backups, monitor clinical data load;
• Work with hospital business and IT SMEs to gather requirements for new implementations and complete user acceptance testing

IT Business Analyst

Confidential

• Perform assessment for the enterprise on ICD-10 conversion project;
• Develop project plan with project managers, conduct user interviews, collect business requirements, facilitate cross-functional sessions, identify areas for business/IT remediation, create business requirement documents for HP QC;
• Perform gap analysis, create workflow diagrams and use case documents, provide project status update, prepare routine presentations for steering committee;
• Lead the efforts of evaluating current top ICD-10 Code Mapping, Financial Neutrality, and ICD-10 Testing Toolkits in the market. Create tool comparison matrix with suggestions to the program director and related departments;
• Perform various ETL tasks and custom coding using SQL Management Studio, VBA, Java to analyze CMS Forward/Backward/Reimbursement GEMs, provide test data sets required by different toolkits;
• Perform detail analysis and ad hoc reports using advanced SQL queries to perform assessment on impacts and evaluate toolkit results, identify design/coding defects and provide feedbacks

Lead Solution Architect/IT Director

Confidential

• Implementing Data Entry system that supports various HealthCare and non-HealthCare file generation, performs various functions such as quality control, data encryption, automatic ftp;
• Lead and perform system/database design for major projects, perform code review for development;
• Lead various X12 and non-X12 EDI integration projects with various adjudication systems;
• Lead healthcare data analysis and reporting using SQL Server, SSRS, Access or customized solutions;
• Define process automation workflow, implement various process enhancement using SSIS and various programming/scripting tools;
• Conduct sessions to create test scenarios, create standard test sets for repeatable testing, interpret results, ensure projects meet all business requirements;
• Lead analysis for internal/external projects, provider professional healthcare IT and business consulting for insurance companies and TPAs;
• Conduct cross-functional discussion with client stakeholders, perform detail analysis on requirements, evaluate resource and cost, provide solutions and proposals for system implementation or integration projects in various business areas;
• Managing onshore and offshore IT resources for system/network administration, security, project development, and customer IT support;
• Conduct routine training sessions with client on various Business Process Outsourcing, lead the efforts of building multiple remote healthcare claim adjudication teams;
• Provide internal trainings on healthcare IT topics, mentor junior team members
• Provide technical/business support for both internal and external users