SUMMARY

• Having 8+ years of working experience in Healthcare and Financial information technology using different tools and technologies to process the claims and submitting the claims and managed the Project with good Production and quality too. Primary Contact person for the whole project for Client call or my management call.
• Experience in importing and exporting data using Sqoop from HDFS to Relational Database Systems (RDBMS) and from RDBMS to HDFS.
• Knowledge and working experience on big data tools like Hadoop, AWS Redshift.
• Expertise in SQL Server Analysis Services (SSAS) and SQL Server Reporting Services (SSRS)
• Excellent understanding and working experience of industry standard methodologies like System Development Life Cycle (SDLC), as per Rational Unified Process (RUP), AGILE and Waterfall Methodologies.
• Good Hands on Experience with Healthcare ad Financial Data Analysis and Put the analysis result into the Reports as Graph or Pivot Tables.
• Good Hands on Experience with Excel, SQL, Tableau and Access
• Proficient in UML Modeling like Use Case Diagrams, Activity Diagrams, and Sequence Diagrams with Rational Rose and MS Visio.
• Excellent understanding on Tableau Workbooks and Background Tasks for Targeted Interactions Validation.
• Having Good Hands on Experience about Healthcare revenue cycle and accounts receivable management, including payment cycles, key trends, and critical success criteria
• Good Knowledge on SQL queries and creating database objects like stored procedures, triggers, packages and functions using SQL and PL/SQL for implementing the business techniques.
• Strong Knowledge of Medical Billing Rules and Regulations to bill the claims to the Insurance offices to get paid.
• Having Good Experience with denial management and appeals processes
• Strong knowledge to handle the 835 and 837I, 837P claims Data Analysis and Strong Experience in Provider Credentialing. Good Hands on Experience with EDI Systems.
• Able to identify performance issues, assess root cause and develop successful action plans for the Production and Quality improvement.
• Have good Hands on Experience working with Physician Claims (HCFA or CMS1500) and Hospital claims (UB04).
• Have Strong Managerial Experience with developing high - performing teams and Achieving the target on time to deliver to Client as they expected.
• Good Understanding of DME Claims adjudication and making a decision whether need to make a payment or deny the claims.
• Having Good knowledge in US Healthcare Industry end to end (Billing Rules and Regulations, Hospital Claims, DME Claims, Physicians office Claims submission and Insurance office all type of Claims adjudication).
• Good Hands on Experience to use ICD 9 codes and Good and Strong Experience on EMR files. Good Knowledge of ICD 10.
• Have Management Experience to handle the team, Project and deliver the quality reports and explain upfront of the management about the Quality of production.
• Have strong experience to generate and deliver the Revenue reports Weekly, Monthly, Quarterly and yearly based.
• Have an Experience Hiring Employees, Appropriate Training and Performance updates to Higher Management and Result in Appraisals.
• Having Experience in billing claims to Insurance Company and adjudicate Physician office claims and Hospital claims as per the plan benefits.
• Strong Experience to work with EDI Claims (submitting and processing claims).
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Have Good Experience to Contact all type of Insurance plans like Medicare, Medicaid, HMO, PPO and POS.
• Have good Experience to Adjudicate and analysis plan and making payment process to the Payer.
• Involved in all type of Insurance adjudication process like Medicaid, HMO, PPO and POS.
• Total Highest Direct Reporters in One Project are 30 Direct Reporters.
• Solid Skills to generate the Reports by Using Excel and SQL.
• Good Hands on Experience to make Pivot Tables and VLookup to analysis the data and making reports.
• Lead the Project and Team members to accomplishment of Project on Time.
• Have good knowledge about financial management skills, including budgeting, forecasting and benchmarking.
• Able to work in a fast-paced, service oriented environment
• Having excellent communication, interpersonal skills and ability to demonstrate emotional intelligence.
• Able to perform multi-task and work with a sense of urgency

TECHNICAL SKILLS

HL7 and Claims billing tools: -All Scripts, Misys, Medical Billing S/w, JACADA and Main Frame.

Data Modeling Tools: Power Designer and Oracle SQL Developer.

Cloud Platforms: Amazon (AWS) EC2, EC3, Elastic Search, Elastic Load Balance.

Operating System: Windows 8/10, UNIX, Sun Solaris.

Database Tools: Microsoft SQL Server 16.0 and MS Access.

BI Tools: Tableau 10, Tableau server, Tableau Reader, Crystal Reports

Packages: Microsoft Office 2016, Microsoft Project 2016, SAP and Microsoft Visio, Share point Portal Server.

Version Tool: VSS, SVN, CVS.

Programming Languages: Oracle PL/SQL, UNIX Shell Scripting

Methodologies: Agile and Waterfalls.

PROFESSIONAL EXPERIENCE

Confidential, EMERYVILLE CA

SENIOR LEAD - DATA ANALYST

RESPONSIBILITIES:

• Involved in Business and Data analysis during requirements gathering. Assisted in creating fact and dimension table implementation in Star Schema model based on requirements.
• Performed segmentation to extract Data and create lists to support direct marketing mailings and marketing mailing campaigns.
• Defined Data requirements and elements used in XML transactions. Reviewed and recommended database modifications
• Analyzed and rectified Data in source systems and Financial Data Warehouse databases.
• Generated and reviewed reports to analyze Data using different excel formats Documented requirements for numerous Ad-hoc reporting efforts
• Troubleshooting, resolving and escalating Data related issues and validating Data to improve Data quality.
• Developed and implemented data cleansing, data security, data profiling and data monitoring processes.
• Involved in Regression, UAT and Integration testing
• Participated in testing of procedures and Data, utilizing PL/SQL, to ensure integrity and quality of Data in Data warehouse.
• Metrics reporting, Data mining and trends in helpdesk environment using Access
• Gather Data from Help Desk Ticketing System and write Ad-hoc reports and, charts and graphs for analysis.
• Compiled Data analysis, sampling, frequencies and stats using SAS.
• Involved in SQL Server and T-SQL in constructing Tables, Normalization and De-normalization techniques on database Tables.
• Identify and report on various computer problems within the company to upper management
• Report on trends that come up as to identify changes or trouble within the systems using Access and Crystal Reports.
• Performed User Acceptance Testing (UAT) to ensure that proper functionality is implemented.
• Guide, train and support teammates in testing processes, procedures, analysis and quality control of Data, utilizing past experience and training in Oracle, SQL, Unix and relational databases.
• Maintained Excel workbooks, such as development of pivot tables, exporting Data from external SQL databases, producing reports and updating spreadsheet information.
• Modified user profiles, which included changing users cost center location, changed users authority to grant monetary amounts to certain departments - monetary amounts were part of the overall budget amount granted per department
• Extracted Data from DB2, COBOL Files and converted to Analytic SAS Datasets.
• Deleted users from cost centers, deleted users authority to grant certain monetary amounts to certain departments, deleted certain cost centers and profit centers from database
• Created a report, using SAP reporting feature that showed which users have not performed scanning of journal voucher documents into the system.
• Created Excel pivot tables, which showed a table of users that, have not performed scanning of journal voucher documents. Users were able to find documents by double-clicking on his/her name within the pivot table
• Load new or modified Data into back-end Oracle database.
• Optimizing/Tuning several complex SQL queries for better performance and efficiency.
• Created various PL/SQL stored procedures for dropping and recreating indexes on target tables. Worked on issues with migration from development to testing.
• Designed and developed UNIX shell scripts as part of the ETL process, automate the process of loading, pulling the Data
• Validated cube and query Data from the reporting system back to the source system. Tested analytical reports using Analysis Studio

ENVIRONMENT: SQL *Loader, Congas, Oracle 11g, SQL Server 2014, Erwin 9.2, Windows 7, TOAD, Tableau, MS Excel, MS Access, Manual Testing. UAT

Confidential, SUNNYVALE, CA

PROJECT LEAD - DATA ANALYSIS

RESPONSIBILITIES:

• Worked as Senior Analyst in Agile Process for Migration Project over the servers.
• Worked with MongoDB, SQL.
• Requirement Analysis, Create Test estimates, Test Strategy, Test Plans, Test Scenarios, Risk Logs, Requirement Traceability Matrix and walkthrough them with Business, Developers, and IT Managers and get approvals for test artifacts.
• Part of team conducting logical data analysis and data modeling JAD sessions, communicated data-related standards.
• Performed Reverse Engineering of the current application using Erwin, and developed Logical and Physical data models for Central Model consolidation.
• Translated logical data models into physical database models, generated DDLs for DBAs
• Performed Data Analysis and Data Profiling and worked on data transformations and data quality rules.
• Involved in extensive data validation by writing several complex SQL queries and Involved in back-end testing and worked with data quality issues.
• Collected, analyze and interpret complex data for reporting and/or performance trend analysis
• Wrote and executed unit, system, integration and UAT scripts in a data warehouse projects. Maintaining testing metrics and circulating it to key stakeholders.
• Work with business users, system analysts, designers and programmers to create and analyze various required project documents
• Hands-on technical Test lead performing test planning and execution of Test Integration activities across multiple platforms/applications.
• Worked in importing and cleansing of data from various sources like Teradata, Oracle, flat files, with high volume data
• Written SQL scripts to test the mappings and Developed Traceability Matrix of Business
• Involved in extensive data validation by writing several complex SQL queries and Involved in back-end testing and worked with data quality issues.
• Created SQL tables with referential integrity, constraints and developed queries using SQL, SQL*PLUS and PL/SQL.
• Performed GAP analysis of current state to desired state and document requirements to control the gaps identified.
• Developed the batch program in PL/SQL for the OLTP processing and used Unix Shell scripts to run in corn tab.

ENVIRONMENT: PL/SQL, Business Objects XIR2, MS Excel, MS Visio, MS Access, Power Point, MS Outlook, Dashboard, Tableau.

Confidential, PLYMOUTH, PA

SR. DATA ANALYST

RESPONSIBILITIES:

• Importing and interpreting source data, Scrubbing, cleaning and validating data
• Preparing input files for 3rd party data processing
• Analyzing the data results and making changes if needed, before presenting the data to project managers and internal consultants
• Able to interpret, scrub, process, and explain data
• Proficiency with Microsoft Office Suite, especially Excel
• Analytical thinker, able to assess problems logically
• Provide data and competitor analytics that enhance and drive sales strategy
• Perform client research and collaborate with sales and leadership team members to determine a comprehensive view of client historical operational, financial and quality data
• Analyze client data to understand historical performance relative to potential performance of products and programs, identify performance gaps and highlight performance improvement opportunities
• Review analytics against Centers for Medicare and Medicaid Services (CMS) model to identify revenue potential
• Develop customized client analytics reports to support sales proposal development and sales presentations
• Ability to understand client operations, financial and quality data
• Ability to identify data discrepancies and produce accurate data analyses
• Ability to conduct competitive research
• Ability to work with and empower others on a collaborative basis to ensure success of unit team
• Knowledge of managed health care industry, health plans and large group physician organizations
• Extensive Knowledge of CMS programs
• Ability to effectively communicate with all levels of an organization both internally and externally
• Excellent analytical, decision making, organizational, creative problem solving, verbal and written skills are required
• High level of proficiency in use of existing software packages and data analysis tools (PowerPoint, Excel, Microsoft Word, etc.)
• Ability to work independently within a team environment with multiple priorities

Environment: Erwin 8.0, Sql, MS Office, MS Visio, SAS/BASE, SAS/Access, SAS/Connect, MS Access, SSRS, Windows 2000, Tableau.

Confidential

SENIOR DATA ANALYST

RESPONSIBILITIES:

• Worked as an internal quality auditor Promoted by Client and Manage the Total project for Production and Quality. Generated the Reports to update to VP of my Project.
• Worked for Enrollment, Insurance Billing and Claims Adjudication.
• Worked on Premium, Self and Individual billing.
• Billing for Group Health insurance, self-insurance and Individual Insurance.
• Being as an Auditor solving all the Queries within the team.
• Assigning the Work to the Processors and auditing work.
• Attend the calls twice in a week for new process and Business updates from client end.
• Took the training classes for new updates, any new scenarios.
• Have good experience to Conducted the errors sessions.
• Explaining the errors which were captured in internal auditing or External Auditing.
• And Giving the Preprocess steps to the team members to do not come across the same error in later days.
• Used to give all the possible ways to remove the error if any error has been tagged to offshore team.
• Processed Health information transformed from System to system individually (HIE and HIX).
• Holding the Claims adjudication Experience, Prepared the notes for Adjudication process for HCFA and UB04 Claims.
• And supporting the team to give the correct payment to the provider with an appropriate adjudication process (if it is a big amount Process only will be done by our team, amount will be released by Client).
• Strong experience to work with EDI Calims processing.
• Good Knowledge and work experience with Medicare, Medicaid and Medical claims for Health, Vision and Dental Plans.
• Strong Hands on experience to work on Workers Compensation claims.
• Wrote a Rebuttal statement with an appropriate reason to remove the error which is charged by External auditing team (MTM Auditing).
• Maintained the quality to make the team as a best team and preparing the team production reports on daily, weekly and monthly basis.
• Prepared the Reports for Internal audit purpose within the Organization.
• Generated the quality report for every day.
• Worked on Enrollment, Crednetialing for all the type of Insurance plans HMO, PPO and POS.
• Worked for all type of insurance adjudication process Medicaid, HMO, PPO and POS
• Took an initiative to prepare the PKT (Process Knowledge Test) paper for every month.
• Preparing and presenting project deliverables and findings to senior project stakeholders and practice area leadership as required, through the use of graphs, tables, and other strategic information to summarize analyses and results.
• Contributing to an innovative and team-oriented work environment with individual accountability and ownership to the success of the practice.
• Knowledge development and continuing to educate and sharing knowledge with QA team members.
• Worked on health information transformation system to system individually (HIE and HIX).
• Conducted the training sessions related to the process and Conducted Health care oriented sessions.
• Handled the team in the absence of team leader or Team Manager.
• Leading and Motivating the team.
• Conducted the Training sessions on the new process or after Client training is over, review of training programmers use to conduct and explain each and every information to the team mates to make the process very easy and appreciated from client.
• Meeting the Production and Quality as per the set targets and standards.

ENVIRONMENT: SQL, MS Office Suit, Excel, PowerPoint, Word, Claims Database, All Scripts, ICD9, Diagnosis codes, HCPCS codes, CPT Codes, EDI Claims Processing, MS Access.

Confidential

DATA ANALYST

RESPONSIBILITIES:

• Worked for Claims adjudication process with the following all the Parameters of Claims Adjudication process (Co-Pay, Coinsurance and Deductible) and Managing the Team and Project.
• Paid the claims with the correct adjudication process as per the Plan benefits.
• Worked on Physician Claims (HCFA - 1500) and Hospital Claims (UB04).
• Worked on Medical, Vision and Dental claims.
• Worked for Pre existing claims. (How to determine the Pre existing condition and what are the benefits and how to pay the claims).
• Worked on Other Insurance, Duplicate claims and Auto accident claims.
• Worked on Corrected claims and Secondary payer claims.
• Being as and Experienced Associate took an Initiate to Explain all the Plans benefits, How to adjudicate a claim for specific treatment as per the plan benefits.
• Handled total 40 plans.
• Took an Initiative to solve the entire team members Queries regarding all the claims.
• Took Initiative to work with EDI Claims and handling claims data base every week.
• Worked for all the insurance adjudication process Medicaid, HMO, PPO and POS
• Handled the Workers Compensation Claims alone in team.
• Strong work Experience with Medicare and Medicaid claims for Medical, and Vision plans.
• Conducted the training sessions on Health care orientation and Claims adjudication process (Explained about CPT codes, Diagnose codes and importance of Modifiers).
• Took an initiative when my team SME / TL absent collated and send the production report and quality report to the Manager on daily, weekly and monthly basis.
• Writing rebuttal statement to remove the error which tagged by onshore team. (Whenever they charged an error mistakenly).
• Apart from the adjudication, worked in Quality department for measuring the Process quality if any errors found charge it to the Respective associate and revised it correctly.
• Meeting the Production and Quality as per the set targets and standards.
• Used to give all the possible tips to the People who are working on Coding process how to code and how to use the code as the geographical area and to make the Physician benefits.
• Having good hands on Experience on Coding the ICD9 Diagnosis codes.
• Having good exposure on CPT codes and Modifiers.
• Good knowledge about the adjudicating the claims and to releasing the checks to the Provider’s offices.
• Preparing and presenting project deliverables and findings to senior project stakeholders and practice area leadership as required, through the use of graphs, tables, and other strategic information to summarize analyses and results.
• Contributing to an innovative and team-oriented work environment with individual accountability and ownership to the success of the practice.
• Committing to knowledge development and continuing to educate and share knowledge with clients and team members.
• Building collaborative methods to develop and share internal reports with peers.
• Expert in Healthcare Knowledge end to end (Physician Billing and Hospital billing and adjudication as well).
• Have Good Experience to Handle the Project with good Planning and managing the team to meet the current goal with good Quality.

ENVIRONMENT: SQL, MS Office Suit, Excel, PowerPoint, Word, Claims Database, All Scripts, ICD9, Diagnosis codes, HCPCS codes, CPT Codes, EDI Claims Processing, MS Access.

Confidential

BUSINESS ANALYST

RESPONSIBILITIES:

• Responsible to enter the Office Visit and Emergency charge Entry for allotted clients.
• Checking patient eligibility with the concerned insurance company.
• Responsible for Capturing the Charge and Billing the claims to insurance companies.
• Responsible for cash posting for allotted clients once we received the EOB.
• Responsible to post the payments which are received while working in AR Process.
• Responsible to make calls to the INS offices to know the denial status of claims.
• Responsible to Coding the Diagnosis code as per the Geographical area and HIPAA rules.
• Leading the Team and Project Management. Client Management.
• Worked in AR process, responsible for Claims which are in 0-30days, 60-90days and 90-120days
• Worked on Denials and Correspondence claims.
• Taking an appropriate action to appeal for Denial claims.
• Worked on Denial Management and Collect the appropriate amount form Payers by submitting all the proofs.
• After done my Initial performance Review got a chance to look over the Project and work maintenance to manage up to date all the time and update the Provider database as well.
• Responsible for allotted clients to prepare the appeal letters for Denials and cover letter for incorrect denials which received from Insurance Companies.
• Worked for Rejections which are received from clearing House and Insurance Company from Pre adjudicate Department.
• Responsible to submit the claims thru EDI and refile the claims thru EDI if any comes back as Rejected or Denied.
• Worked with Medicare, Medicaid, HMO, PPO and POS organizations for Denial or Rejections management and appropriately used to make appeal too.
• Worked on ICD9 codes (Coding Dx for doctors Listed Symptoms of Patient to send to Insurance office to get claims paid).
• Worked on live calls of commercial Insurances (making calls to the Insurance companies to know the status of Denial claims and update the status into the software as per insurance representative’s responses).
• Maintaining the ageing report to collect the outstanding amount from the Insurance Company to Provider Office.
• Worked on Medicare IVR Calls.
• Good Hands on Experience with Misys and All scripts.
• Meeting productivity and quality levels according to set targets and standard.
• Updating and maintaining the Check log on daily basis.

ENVIRONMENT: SQL, MS Office Suit, Excel, PowerPoint, Word, Claims Database, All Scripts, ICD9, Diagnosis codes, HCPCS codes, CPT Codes, EDI Claims Processing, MS Access.