SUMMARY:

• Possess 6.5 years experience in Information Technology with emphasis on EDI & business /system analysis of applications and validation of requirements for different business scenarios. Well versed with all aspects of Software Development Life Cycle such as water fall and agile methodology and Involved in stages such as Requirement Gathering, Analysis, Design, Validation and Quality Assurance. Expertise in data analysis of Medical codes processing (ICD 9/ICD 10) such as procedure codes and diagnostic codes, EDI 5010/4010 and other proprietary claim processing in HealthCare Industry. Experience in working in requirement and defect tracking tools such as HP Quality center, IBM Rational Requisitepro, Mercury Test Director. Have 4 years of experience in operational support and maintenance of huge applications.
• Technical Experience:
• IBM WTX, Mercator, Ascential Datastage Director, Med Stat Build Manager.
• FileAid, Xpediter, Easytrieve.
• Programming Languages: PL/SQL, UNIX Shell Scripting, Pearl.
• Databases & Tools: Oracle 9i, TOAD, SQL, Oracle SQL Developer, DB2, Platinum.
• Other experience includes worked in diverged applications such as Clearing House, Data warehouse, Third Party Administrator, Trizetto Facets, Payment Engine. Facilitated data transfers in these systems internal and external using encryption methods which includes PHI information. Excellent documentation skills involving MS Office suite.
• Electronic Data Interchange EDI: Knowledge in various EDI standards 4010/5010.837 Claim Professional & Institutional, 835 Payment & ERA, 834 Benefit Enrollments, 820 Premium Payments, 27X Request and Response Transaction.

Medical Code Processing Experience:

• Work experience with ICD9 and ICD 10: Performed Analysis on the denied claims relating to ICD9, and CPT codes both for Inpatient, outpatient claims and routed them to resolution bucket.
• Involved in the Phase of analysis/research for conversion of ICD9 to ICD10-PCS and ICD10-CM codes which was apart of EDI 4010 to 5010 conversion project. Explored Technical options of accommodating new ICD10 codes replacing ICD9 in Facets claim processing systems and TPA. For Field expansion project for 5010 and ICD10 project in Mainframe systems provided analysis and scoping.
• CPT Codes & HCPCS: CPT codes (0*-9*) HCPCS codes (A*-Z*) codes for product, medical supplies and service which are not covered in CPT codes.
• Medical Revenue Codes: Assigning/verifying correct Revenue code for different Inpatient, outpatient in TPA and Facets Systems.

WTX CONSULTANT AND EDI ANALYST-OFFSHORE:

• In-depth understanding of technical design of the system.
• Delivery point of contact and Subject Matter Expertise. Co-coordinating Business and Development team at offshore.
• Performance tuning of the system and undertaking an alternative way to stabilize the system.
• EDI File and other proprietary file structure analysis develop and deploy them in production environment. Deployment of the modified/developed maps and scripts and testing of the same.
• Perform the testing of the changed maps and scripts by preparing test cases and test files.
• Facilitating Unit testing, Functional testing.
• Application and system Maintenances. Performing tasks using HPSD for request and incidents.
• The test logs are then updated with the details obtained from the detailed testing carried out. Ensure the quality in the deliverables and perform the metrics analysis.

BUSINESS ANALYST/BUSINESS SYSTEM ANALYST ROLE IN PROJECTS:

• Requirement gathering and analysis for the critical business needs.
• Requirement documentation and tracking.
• Documenting High Level Application Design and Process.
• Designing and documenting Application Interface and User Interface document.
• Facilitating Joint Application Design (JAD sessions).
• Rate/Fee scheduling process for each procedure codes for providers.
• Analyze healthcare claims and validate (test environment/pre production environment) different business scenarios for procedure and diagnostic codes.
• Facilitate meetings with Key business stakeholders to prepare test cases based on business scenarios.
• Complete understanding of system and Work with development on an ideal design.
• Ensure the quality in the deliverables and scope for business improvement.

UAT & E2E testing

• Strong experience in conducting User Acceptance Testing (UAT).Involved in following UAT testing process preparing UAT test plans for business requirement, Identify business scenario for testing, identify the correct data & execute test cases, Analyze the results, Track defect and summarize report.
• Perform the validation of implemented business scenarios (UAT and E2E).
• Clear understanding of business requirement at program level to perform UAT.
• Facilitate meetings with key business stakeholders to understand and document different business scenarios for UAT.
• Worked extensively with Quality Center for requirements, Preparing Test cases, Executing, Defect openings and closings. Other tools are Mercury Test director, IBM rational reqpro
• Training Quality Assurance team to understand the requirement and manage the timely delivery. Assist them with different System Integration Testing (SIT).
• Executed a whole bunch of PL/SQL code including stored procedures, functions and triggers using TOAD.
• Involved in writing UNIX shell scripts and Perl shell scripting
• Extensive working experience in cross application environment both internal and external.
• Experience in handling file transfer and data communication outside the network in secured manner using pgp and other encryption methods.

DETAILED PROJECT SUMMARY

Application,Projects:Confidential,Shared Vendor Data Hub. ,Global Payments

Duration:August 2012-Current

Hardware:Windows NT Workstation

Application:PeopleSoft AP, Ariba, Archer, Field glass.

Database:Oracle

Location:Minnetonka,MN

Project Description
Supplier Data Hub Establishing centralized data hub for all vendor profile data. This helps the interacting systems to have common access point for data. This project solution provides higher data standard, removes duplicates and provides data governance on each profile data.
Global Payments -As an organization grows domestically and internationally, the need for Payment Services to make payments on behalf of legal entities in various countries, to [foreign] vendors in their local currency via an [electronic payment] or paper [check] method will continue to grow. There is always a scope to improve the business process around handling money transactions and standardize the process across the globe.

APPLICATION/PROJECT 2:

Application,Projects:Confidential,Payment Engine/CAMS,Member Data Security,User Profile Enhancement

Duration:May 2011-August 2012

Hardware:Windows NT Workstation

Middle Ware:IBM WTX, PX

Database:Oracle

Other Details:Req Pro

Location:Minnetonka,MN

Project Description
Affordable Healthcare Act 2010 deals with the calculation of Medical Loss and rebates the premium back to the employer/subscriber. The assignment involves the health care reform mandate; Insurance companies need to pay back specified percentage of the member/employee group premium to the member/employee group if the claims are less than the set threshold percentage by the government.
Member Data Security & User Profile Enhancements -Consumer account management system is an independent platform for claim process and adjudications. Member Data Security Project involves re design of CAMS user portal to enhance different functionality such member, claim and payables. Enhances the user security levels and provides adequate difference between different statuses of the user account.

APPLICATION/PROJECT 3:

Duration:June 2010-April 2011

Hardware:Mainframe

Database:DB2

Other Details:Lotus Notes, PIPP

Project Description
ANSI 5010 and ICD10 Migration - Implementation of government mandated EDI 5010 implementation across the healthcare industry. Analysis and scoping of ICD10 impacts claim processing business rules.
Field expansion Project involves preparing system ready for ICD10 implementation in 2013. This work is related to impact analysis on database for new ICD10 codes, making the system ready for longer ICD10 codes and identifying key business process impacted.
Fees and Rate schedule, involves scheduling fees and rate for each provider unit and validating the procedure codes in pre production environment before it is implemented in production environment.

APPLICATION/PROJECT 4:

Application,Project:Confidential,UBH/PBH.4010-5010 Migration & ICD10 expansion,Facets System Upgrade

Duration:March 2010- May 2010

Hardware:Windows NT Workstation

Middle Ware:IBM WTX, PX

Database:Oracle

Other Details:Req Pro

Location:Minnetonka,MN

Project Description
4010-5010 Migration & ICD10 expansion – Implementation of government mandated EDI 5010 implementation across the healthcare industry. Analysis and scoping of ICD10 impacts claim processing business rules. This system involves the behavioral claim processing of United Health Group.
Facets System Upgrade – Current version of Facets system will not be able to accommodate all the changes in 5010 and ICD10, this project involves the impact analysis on each business rules impacted by the above migration and making the system ready for 5010 and ICD10 changes.

WTX CONSULTANT AND EDI ANALYST:

PROJECT PROFILE 5 UHG IT- Definity Health DW (Mar 2008 - Feb 2010)
Project Description Definity Health supports following products for their customers CDHP, HDHP, HRA, HAS, StayWell. Datawareshouse stores claims and creates report claim and eligibility reports. It supports following formats, 837 835 834 file formats and proprietary formats.

WTX CONSULTANT AND EDI ANALYST-OFFSHORE:

PROJECT PROFILE 6 WellPoint-Anthem Mercator
Project DescriptionWellPoint Clearing House is the EDI processing system of WellPoint, which is developed with Mercator. This is a business critical system as it forms the gateway for all types of transaction to enter the WellPoint system from external world. Transactions from all regions are made to receive by a single clearing house and the HIPAA validations are done for the same. The migration projects handled by Mercator validate the transactions and route them to different processing systems of WellPoint instead of a third party adjudication system.

CLIENT PROFILE:

Confidential,2008-March-Current (Client)
UnitedHealth Group Incorporated provides healthcare services in the United States. It was founded in 1974 and is based in Minnetonka, Minnesota. The company’s Health Benefits segment offers consumer-oriented health benefit plans and services, administrative and Non-employer based insurance options for purchase by individuals. In addition to health benefit plans, offers specialty care programs such as vision, dental care, HSAs (health savings accounts) and HRAs (health reimbursement accounts).United Healthcare National Accounts creates customized health benefits solutions to meet the often complex needs of large sophisticated multi-location employers and also provides health care services for employees located overseas.

Confidential,May 2006-March 2008 (Client)
WellPoint, Inc. is an Indiana-domiciled, publicly traded company that, through its subsidiary companies, provides health care benefits to millions of people. WellPoint is the largest publicly traded health benefits company in the United States and an independent licensee of the Blue Cross and Blue Shield Association. Anthem, Inc. and WellPoint Health Networks Inc. completed the merger on Nov 30th 2004. Anthem, Inc., the corporate parent, has been renamed WellPoint, Inc., and WellPoint, Inc. now serves approximately 28 million medical members through its Blue Cross or Blue Cross and Blue Shield operations in 13 states and its non-Blue branded operations in other states. WellPoint, Inc. is the largest publicly traded commercial health Benefits Company in terms of membership in the United States. WellPoint, Inc. is an independent licensee of the Blue Cross and Blue Shield Association and serves its members as the Blue Cross licensee for California; the Blue Cross and Blue Shield licensee for Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia and Wisconsin.

Other Information:

Bachelor of Technology - Information Technology, Confidential,University
Experience: 6.5 Years.
Industry: Confidential