SUMMARY

Over * years of experiences in software and Healthcare Industry.

Experience in claim processing, Adjudication and Payment.

Posses both Healthcare business and Technical knowledge with various systems such as Clearing house, Datawarehouse, Facets, Trading Partners and Payment Engine.

SPECIALITY SKILLS

5010 EDI Claim – Professional & Institutional

Medical Code Processing: Procedure codes (ICD9, HCPCS), Diagnostic codes & Revenue codes

Software Development Life Cycle Involved in stages Requirement gathering, Analysis, Design, Validation and Quality Assurance, RSA Methodology.

Documentation: MS (Word, Excel, Access, PowerPoint, Publisher), MS Viso, HP Quality center, Test Director, IBM Rational Requisitepro

SOFTWARE SKILLS

Utilities: BM WTX, Ascential DataStage TX 7.5, Ascential Datastage Director, Med Stat Build Manager, Test director, Quality Center,PIPP,FileAid.Xpediter,Easytrieve HPSD

Programming Languages: UNIX Shell Scripting, PL/SQL, Pearl

Databases & Tools: Oracle 9i, TOAD, DB2, Platinum

EMPLOYMENT HISTORY

UNITED HEALTH GROUP -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.

BUSINESS ANALYST/BUSINESS SYSTEM ANALYST ROLE IN PROJECTS:

Requirement gathering and analysis of the critical business needs.

Sound knowledge in US healthcare Trend.

Complete understanding of system and Work with development on an ideal design.

Perform the validation of implemented business scenarios (UAT and E2E)

Ensure the quality in the deliverables and scope for business improvement.

PROJECT PROFILE 1: UHG IT-Payment Engine (May 2011-Current)

Project Detail: Affordable Healthcare Act 2010

Project Description Affordable Healthcare Act 2010 deals with the calculation of Medical Loss and rebates the premium back to the employer/subscriber. The main functionalities of Strategic Payment Program are Payment Consolidation, Overpayment Recovery, Provider EOB, Voids and Stop Payments. 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.

PROJECT PROFILE 2 UHG IT-UMR TPA(June 2010-April 2011)

Project Detail: ANSI 5010 /ICD10 Migration, Fees/rate scheduling

Project Description UMR is the largest third Party Administrator (TPA), offers the flexibility of local TPA with the scale, reach and cost savings of national organization. Process over 40 million claims a year and services more than 1260 clients, almost 3 million plan members. Services include Medical, Dental, Vision and disability. In addition, offers administration for Retiree carve-out, Taft-Hartley plans, Municipal sector business. Variety of in-house products to help clients manage their benefit plans and control their costs such as Care management (utilization, case, maternity, disease management and health and wellness programs), Pharmacy benefits administration, Claim recovery management, Reinsurance products and services, Claim repricing and provider data management software and services and Non-network claims cost containment

PROJECT PROFILE 3 UHG - OptumHealth Business Operations-Facets (Mar 2010-May 2010)

Project Detail Facets System Upgrade and HIPAA EDI 4010-5010 Migration

Project Description Optum Health behavioral Solutions process the behavioral claims for United Health Groups. Claim Processing and Adjudication of the BH claims are maintained in Facets system United Behavioral Health/Pacific care Behavioral Health (UBH/PBH). Receives claims in EDI and paper format, processes and pays as electronic and paper payment. Storage and retrieval of eligibility, provider information and check disposal are maintained in separate database. Uses Duncan for the Manual check disbursement.

LEAD DEVELOPER ROLE IN THE PROJECTS

In-depth understanding of technical design of the system.

Performance tuning of the system and undertaking an alternative way to stabilize the system.

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.

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.

PROJECT PROFILE 4 UHG IT- Definity Health DW (Mar 2008 - June 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.

WELLPOINT, Inc -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.

PROJECT PROFILE 5 WellPoint-Anthem Mercator

Project Description WellPoint 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.

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