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Click here or scroll down to respond to this candidateCandidate's Name
PHONE NUMBER AVAILABLE EMAIL AVAILABLESummaryOver 9 years of experience in the IT field as a Facets/EDI/Business Analyst with a thorough knowledge of Software Development Life Cycle (SDLC) and RUP including requirement capture, analysis, design and development. In-depth knowledge of business processes in Healthcare industries. Experienced in Business Requirements gathering and managing, Risk Analysis, Gap Analysis, Feasibility Studies, and UML Modeling. A result-oriented enthusiast, with highly developed planning, analytical, technical communication, decision-making and leadership skills, driven with the ability to multitask and deliver effectively, in a fast-paced environment. CertificationsSix Sigma Green Belt Certified (SSGBC).SkillsServed as a business analyst developing and prioritizing User Stories in SCRUM.Adequate knowledge in Health Administration Claims processing (auto adjudication), Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, MedicaidInvolved in JAD, walkthroughs and various meetings with the stakeholders of the project including technical users in order to design complete and detailed documents such as Business Requirement Documents, Functional Requirement Documents, Use Case Diagrams and Activity Diagrams.Evaluated and analyzed the current business models of a company; performed GAP Analysis; generated AS IS and TO BE process flows.Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI) in 4010 and 5010 formats.Involved in claims submission and payment (remittance) retrievals and used HIPAA X12N 820 for the inbound premium payments. 837 - Claims and Encounters 834 - Benefit Enrollment and Maintenance accumulators. 835 - Claim Payment/Advice 270/271 - Eligibility Benefit Inquiry and Response 276/277 - Claim Status Request / ResponseExpertise in creating SQL Queries for business analysis.Experience in using requirement management tools, such as IBM Requisite Pro, HP Quality Center. Professional ExperienceCorewell Health, Remote April 2021 PresentTitle: BA/EDI/Facets AnalystRoles and ResponsibilitiesCreated mapping documents and tested Institutional/Dental/Professional EDI 837 and 834 EDI files.Wrote SQL queries to track claims data from EDI legacy all the way to FACETS core. Analyzed and traced data elements such as C Codes for routing claims to trading partners and claim notes to design a new process for outsourcing the claims to the repricing vendor.Wrote SQL queries to verify the return flag values and mapped values in vendor return file.Created mapping document to map Facets claim fields (CORE Claim Data Model) to XML for the outbound file to the EDI legacy.Created Stories on JIRA for turning the status and lock claims while waiting for the file to be returned by vendor.Did analysis using SQL to load the return file to XC, then CORE Facets claim tables.Created process flow for sending receiving 837 EDI files from trading partners, loading in EDI legacy and rerouting to the vendor for repricing.Created XC load mapping for EDI 837 claim files to be loaded in Facets after the Repricing.Performed analysis on Facets out of the box feature Publish Button to replace Send No Send custom extension for manually adjusted accumulators. Did POC from hitting the button at Member/Family level for each Accumulator Type D/L with MCTR REASON to trigger windows server (Outbound Publishing) for populating DOTS and message queue picking it up for EWS to the Pharmacy vendor. GRAF/AFGAP configuration.Perform analysis on Facets benefit 360 app by measuring the impact on different external apps using BSD, BSBS and BSTX.Created HLD to extract Medical and Mental First Dollar Choice Accumulators out of Facets and submit OB to Magellan.Worked on first pass and second pass Payment integrity feeds(Appeals and Grievances) for multiple vendors in order to reduce the claim adjudication costs using vendor edits.Created user stories on Jira for MCC payment integrity for Medicaid LOB.Created and designed provider portal screens for HHP program.Created SQL cookbook for Oracle DBMaintained data dictionary for the caretaker schemaCreated BRD for HHP eligibility extract OB.Designed EDI 837 ENCOUNTER OB claims to DHS for HHP members.Created test cases for testing Individual and Group Enrollments.Created EDI 834 mock files for initial enrollments, termination, cancelation, reinstate scenarios using EDIFECTS.Ran test scenarios by directly calling Facets using EDIFECTS contract XML via postman API calls.Analyzed requirements for Race and Ethnicity data in EDI 834 for Individual enrollment.Analyzed requirements for PCP assignment process and raised defects for webservice and EDIFECS defects data in EDI 834 for group enrollment.EmblemHealth, New York, NY Feb. 2019 Jan. 2020Title: Facets System AnalystRoles and ResponsibilitiesCreated a custom process to run at the step 10 of the CLMU picking up all the 01 status claims and apply override with an EXCD ID to be picked up by work flow so business could review the claims. The job would run between CLMU and CKMM batch job.Created a process to identify members based on warning messages in CMC MEWM MSG with a specific sequence number during CLMU run to identify Medicare claims and suppress the maximum out of pocket amounts at line level so that cost share wouldnt be counted toward MOOP.CDML collection which is the xml holding the CDML table was quoted for a specific LOBID checking the ACAC ACC No. If there was a match the logic would suppress the record.For billing created a process to load the PUB file for individual and group payments and apply the payment in Facets RCPT table for the Billing invoice ID sent by the bank. The logic would locate the entity based on its billing level and SGDG ID and GRGR ID so the keyword would be created to feed the BRCP batch Geisinger, Bloomsburg, PA April 2018 Feb. 2019Contractor: System Analysts Inc (Hire IT Global Inc) Title: Facets System AnalystRoles and ResponsibilitiesCreated a BFD (Business Functional Document) for Billing PACE and PACENET Billing Invoice extract to CMS.Created a BFD for generating a process to put conditional FFM Enrollments on hold until the Binder Payment is paid generating conditional pre-warning cancelation messages to business.Created a BFD for PA Employee Trust Fund claim extracts out of Facets.Created a BFD for Verizon Claim extracts out of Facets core.Created a BFD to load Inbound Pharmacy and Medical Accumulator files from Evolent and load them in Facets so the Med-impact sweep job would import the date and an outbound extract subsequently be created and submitted to Evolent containing copay, max out of pocket, deductibles for Eastern Maine.Created a BFD to load 820 EDI file coming from CMS into Facets and ODS. Replicating the data from EMMA generating internal reconciliation reports. Worked closely with the Finance to set up the billing group in order to load APTC and Premium amounts at billing group level but the Receipts at subscriber level in RCPT.Created a BFD for Med-Supp LOB to generate letters.Created a BFD for IDN to pick up the denied claims in Facets for specific EXCD codes and submit a claim extract so denial letters could be generated. Worked heavily with provider team to set up online screens to handle one time providers known as ZZ using IPCD and RCRC codes.Utilized Facets knowledge in provider domain to create SQL provider reports before go live for Monarch migration project.Responsible for writing provider business requirementsResponsible for logging defects in production and running SQL validation queries to support the provider teamExcellent command of Facets front and back end tablesStrong knowledge of Medicare/Med-Supplement and Commercial plans.knowledgeable around NetworX Pricer providing good examplesCreated use cases and wrote user-stories in Agile environment using Rally for Facets configuration.Worked with IT on XPF load job issues.Scheduled JAD Sessions inviting business owners, architects, QA, DEV and Scrum Master to either gather requirements or discuss specific road blocks while implementing Facets.Created BFDs (Business Functional Documents) to present the ask, current process (As Is), Future State (To Be) and suggested solution as well as defining scope and constraints and dependencies. Automated Benefit Services, Sterling Heights, MI Sep. 2017 March 2018 Contractor: Dolphin Solutions IncTitle: Facets System AnalystRoles and ResponsibilitiesTrillium Project (Facets Implementation 5.5 Version): Designed a custom process to assign appropriate Providers to Dental, Vision, FSA and Medical claims in XC. Performed POC to adjust options in Facets HIPPA Gateway by creating mock EDI 837I and 837 D. Created the design for Accum migration and Accum Sync. Created Keyword file for ABIX and ABEX.Did gap analysis for MATX/MEAC and FATX/FEAC in order to use 5.5 Accumulator data model and transfer concerns to business for the new Trizetto changes. Created mapping for EOB/EOP in order to send the extract to the print vendor migrating from legacy system to Facets. Mapped medical,dental,FSA and HRA data from Facets Accounting Data model. Created design and mapping to Billing Invoice. Worked on BLAF and BLIO jobs. Roles and ResponsibilitiesTranslated business needs into system/technical requirements by creating Technical Design Documents (70 percent):Designed and created TDDs (Technical Design Document) as a system analyst for the organization in order to migrate to Facets 5.5 (this is the latest version of Facets) from module Networx and SQL Server as their Database for Provider Match process grabbing CLST Status 16 Medical and Dental claims and assigning the correct provider ID to them for CLMU run in order to adjudicate claimsDeveloped a new logic to assign the SE Providers to claim in TDD by implementing Gap Analysis showing the current and future state and the flow of data from the Gateway to the different XC tables and mentioning the step by step actions needed to be taken by the code using MS VISIO.Conducted extensive Gap Analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system (LuminX) to FACETS (Client Server based system).Prepare system diagram, workflows, data flows, and sequence diagrams using VISIO and including in TDD in order to show the impact of the design on other systems and analysis of how the new built in the system could be possibly coded stating Job names, Table names and Primary Keys linking tables in FACETS data model.Analysed defects in XC, mocked X12 transactions running ErCcsRun837i and CKMM jobs -compared them and found the problem that is causing to pend the claims.Created Multiple POCs loading EDI 837 files on the server utilizing Insert, Update functions with SQL language in order to test the CLMU provider pick logicUsed SQL Management Studio to write SQL queries such as inner join, left join and Update statements in order to test ETL load jobs in development, QA and SIT.Re-engineered and captured transactions with legacy systemsX12 Institutional and Professional -837Extracting informationViewing numbers and figuresRepresenting what learnt in the form of charts and graphsProviding recommendations and areas that needs improvement Product (Facets Job) Requirement Analysis:Mapped X12/EDI transactions to the standard internal format (Facets Keyword) and prepared mapping documents (20 percent).Analyzed FACETS data tables and created a keyword-based fixed-length file format for feeding the UM job.Analyzed CKMM job tables and created the job feed to generate EOB/EOP.Performed forward and backward data mapping between fields in BizTalk and FACETS.Used SQL queries and manually loaded data into FACETS to test internal business rules.Performed data recovery and replay operations for reporting and cleanup of HIPAAcompliant EDI transactions(270/271, 276/277, 837, and 835).Group Meetings and Discussions:Followed a combination of Agile and Waterfall SDLC methodologies to implement the migration (10 percent).Participated in management structure and portfolio discussions, focusing on roles, responsibilities, and organizational titles.Illustrated the current scenario, including the As Is status, future plans, and expectations for upcoming work.Addressed problems and solutions, discussing existing issues, potential solutions, opportunities for cost savings, and strategic planning and execution.United Health Group, Phoenix, AZ Feb. 2016 July 2017 Contractor: Compuga IncTitle: Facets System AnalystRoles and ResponsibilitiesOptum(UHG), provides information products, advisory consulting services and business process outsourcing to participants in the health care industry. Hospitals, physicians, commercial health plans, government agencies, life sciences companies and other organizations that comprise the health care system work with OptumInsight to reduce costs, meet compliance mandates, improve clinical performance and adapt to the changing health system landscape.project 1:Designed a process for Medicaid claims to remove prompt payment discount on professional and hospital claims to prevent applying both prompt discount and interest on the same claim. Waterfall methodologyproject 2:Designed a process to identify claims based on their rejection flags coming from upstream application and created a job to split the adjusted and manual claims and new claims to be rejected before they hit the Facets XC therefore reports could be generated. Helped product owner create user stories in Rally for implementing project in agile Created tasks for multiple agile team members after daily scrum call in order to track work Assisted scrum master in allocating reasonable resources for agile sprints and determining duration of sprint for each release. Contributed in prioritizing coding of user stories Helped estimating tasks for dev and testing team in sprint zero planning session Created solution for agile user stories, finalized, got approval and supported testing, coding and deployment. Helped product owner to clarify user stories adding acceptance criteria, notes and attachments to the user stories. Participated in retrospect meeting for lessons learntproject 3:Created a solution to add disclosure info coming from third party vendor database sending in the outbound provider extract to the state modifying layouts and file transfer. Helped product owner create user stories in Rally for implementing project in agile. Created tasks for multiple agile team members after daily scrum call in order to track work Assisted scrum master in allocating reasonable resources for agile sprints and determining duration of sprint for each release. Contributed in prioritizing coding of user stories. Helped estimating tasks for dev and testing team in sprint zero planning session. Created solution for agile user stories, finalized, got approval and supported testing, coding and deployment. Helped product owner to clarify user stories adding acceptance criteria, notes and attachments to the user stories.project 4:Created a new design to intake a feed from state containing provider info and load into provider database as well as loading TPV file into vendor database. Helped product owner create user stories in Rally for implementing project in agile. Created tasks for multiple agile team members after daily scrum call in order to track work. Assisted scrum master in allocating reasonable resources for agile sprints and determining duration of sprint for each release. Contributed in prioritizing coding of user stories. Helped estimating tasks for dev and testing team In sprint zero planning session. Created solution for agile user stories, finalized, got approval and supported testing, coding and deployment. Helped product owner to clarify user stories adding acceptance criteria, notes and attachments to the user stories.project 5:Created 3 designs for an end to end process to replace vendor vision for a state. Worked on TPV load, paper provider directory, find a doctor app. created a new feed for sending EDI 834 outbound eligibility file to vision vendor. Worked on sending vendor claims to feed the encounter data base for both Medicare and Medicaid members. Helped product owner create user stories in Rally for implementing project in agile. Created tasks for multiple agile team members after daily scrum call in order to track work. Assisted scrum master in allocating reasonable resources for agile sprints and determining duration of sprint for each release. Contributed in prioritizing coding of user stories. Helped estimating tasks for dev and testing team In sprint zero planning session. Created solution for agile user stories, finalized, got approval and supported testing, coding and deployment. Helped product owner to clarify user stories adding acceptance criteria, notes and attachments to the user stories.project 6:Created SSD and HLD for sending the Feed to Nemis. As part of the MS CHIP Encounter implementation into NEMIS and moving to 837 outbound files, the State was requiring the passage of the CHIP ID for atypical and non-par providers that dont have an NPI. As a result of this project The CHIP ID captured and retained in the AuxDB, therefore the CHIP ID was included in what is passed to NEMIS for encounter purposes.project 7:Created SSD and HLD for Living Arrangement/Institutional Status Fields to reside on Facets tables: there were new data fields in the 2300 Loop/HD04 Segment (Health Coverage) containing Living Arrangement and Institutional Status values. The state expected the health plan to utilize this new data to understand where the member is residing for improved member contact and care coordination. Due to this information, these new data fields needed to be loaded into CSP Facets.project 8:Created SSD and HLD for generating LA COB Outbound file from CSP Facets to State as per the states new business rules for sending the below mentioned fields: recipient ID, zip code, Carrier Code, Expiration Dateproject 9:Arizona State Migration-Finance Vendor and PCP Capitation. Created artifacts for migration of Arizona plan implementing in the facets platform. Created high level design document to address the changes to the Facets Vendor /PCP Capitation process which needed to be modified to include Arizona. As a result, Facets currently pays Capitation to Vendor (Global Capitation), PCP (PCP Capitation) and IPA (Secondary Capitation).project 10:Created artifacts for establishing a new FAD for PA DSNP member in order to help customers choose the right provider.project 11:Created artifacts for modifying the auto PCP assignment in order to assign providers with blended lines of business to members. Change the logic to send network sets instead of network prefixes.project 12:Created artifacts for creating a new store procedure in order to apply zero copay amounts on 837 non-emergent claims filtering based on procedure codes and diagnosis and bill types for multiple states.project 13:Created artifacts for creating an automated process to pick up rejected claim from multiple rejection points throughout the system and send the report feed to a particular data warehouse for the usage of Business Intelligence team as well as providers.project 14:Created artifacts for creating an automated process to pick up 837 AZ professional and Hospital claims and remove prompt payment discount on them in order to preclude application of both prompt and interest at the same time. Designed a new custom process within CKMM.project 15:Designed a process for Skilled Nursing Facility and Home Health claims to be priced based on Date of service while others should continue to be priced based on Admission date. SNF claims should be denied at line level if they have date of service spanning over multiple months. User should be able to view original admission date on claim through front end and encounter extract should not send date of service in place of admission date for this process.Roles and ResponsibilitiesPrepare system diagram, workflows, data flows, sequence diagrams.Translate business needs into system/technical requirements (e.g., Solutions Summary Documents, Detailed System Specifications, Mapping documentation)Map X12/EDI transactions to standard internal format; prepare mapping documentsCommunicate and collaborate with design teamPresent designs to potentially large audiencesPrepare workflows, data flows, sequence diagrams.Work on new design implementationsAbility to prioritize tasks across multiple projectsIdentify ambiguity in requirement and solution documentsCreate/contribute to project estimates (e.g., Budget Guidance, Solution Analysis, and Design Estimates)Ensure that system solutions are thoroughly researched, analyzed and documented HealthPlan Services, Tampa, FL MAY 2015 Oct. 2015 Contractor : SCM Data May to AugustContractor : Lancesoft Inc August to OctoberTitle: EDI AnalystWorked on three state base exchanges that are Kentucky and Colorado and Idaho. For these three states I am the point of contact from HPS.Managing membership with these two states.Wrote requirement documents like BRDs, FSDs, process flow, and inbound/outbound 834,820 and 864 and Gorman mapping.Research HPS system, inbound/outbound 834,820,864 EDI files in case of any issue/discrepancy with one or multiple members.Touch base with state point of contacts if we need any information/confirmation from State Exchange.Working on processing of 2016 renewal membership from state exchanges of CO.Working on recon process for membership from state exchanges of KY and CO and ID. EducationMasters in Industrial and System Engineering Sept. 2012 Apr. 2015 University of Michigan-DearbornPHONE NUMBER AVAILABLE EMAIL AVAILABLE |
