Quality Management
Resume:
Vijaykumar Gandham
**********@*****.***
Profile Summary
Worked with United Health Group as Quality Analyst in BOM (Business Operation Management) from November 2014 to April 2015.
Over all 2+ years of experience in healthcare and IT industry as Pharmacy / Business Benefit Analyst.
Involved in the verification and auditing the claims for completion of the project as a Quality analyst worked on IT applications as PEGA and AS400.
Implementation, development, enhancements, up gradation, rolls out and support projects, with proven track record of company and customer satisfaction.
Worked as Management Trainee for 1 year in Sanat Products Ltd.
Professional Summary
Worked with Magna InfoTech and Client being Optum Rx PBM Team which is associated with United Health Group as Pharmacy Benefit Analyst in PMB industry from December 2012 to August 2014.
Audit the documents and applications of projects implemented by the implementers as a quality analyst by analyzing Rx claim machine and planning documents comparing with SOPs.
Hosting process meetings with associates working in the same process both onshore and offshore.
Analyze benefit requests and secure all necessary data to ensure appropriate implementation based on applied logic of Rx CLAIM / AS-400 pharmacy claim adjudication system.
Work with Client Management to implement new and maintain existing benefit plans and client pricing in the pharmacy claim adjudication system.
Work with Clinical Pharmacy to implement formulary updates and clinical programs in the pharmacy claim adjudication system.
Work with cross functional teams to Ensure timely communication of any issues and/or information needed to complete a plan request.
Managing with Pharmacy Network Management to implement pharmacy rate changes and network additions in the pharmacy claim adjudication system.
Develop client specific implementation plans and manage implementation processes in accordance with department protocol.
Run queries out of the RxCLAIM/AS-400 adjudication system to secure all necessary information to implement plan requests.
Develop and run macros in RxCLAIM/AS-400 to implement plan requests.
Perform claim testing to ensure accurate claim adjudication.
Maintain acceptable and appropriate quality levels and production turnaround times.
Adhere to all documentation standards within the department and Assist with the development of process improvements for the department.
PhBit Research and respond to all claims processing inquiries from Client Management, Clinical, and other internal department.
Participate in team meetings and team huddle. As per business requirement, assigned to work on special projects and business initiatives.
Create qualification and validation deliverables, such as validation master plan, risk assessment document, validation (e.g., IQ, OQ, and PQ) protocols and reports, commissioning plan and validation summary report
Experience in authoring and reviewing URS (User Requirement Specification), FRS (Functional Requirement Specification) and executing of IQ/OQ/PQ test cases in a GXP environment
Strong knowledge about FDA pharmaceutical/medical device regulations like 21 CFR Part 11, Part 210, Part 211, Part 820, ISO 13485 & 14971
TECHNICAL SKILLS
Command on IT applications as PEGA and AS400.
Operating Systems: Unix, Win200X/XP/NT/7, and Linux
Tools: MS Office (Word, Excel, PowerPoint, Access, Documentum, Quick Test Pro, SharePoint, HP ALM
SDLC/Methodologies: Waterfall, Agile, Scrum
Primary Responsibilities
Work with cross functional teams to suggest, implement and document process improvements.
Responsible for meeting turnaround times, quality measurements and performance guarantees.
Follows all policies and procedures relating to job function.
Analyze client documentation against system set up to identify defects.
Utilize both manual and automated testing processes to determine accuracy of benefit coding.
Reporting defects identified during testing to appropriate departments consistently until resolved.
Effective in the utilization in various aspects of Quality Excellence including; software, tools, procedures, best practices etc
Performs other duties as assigned to meet corporate initiatives
Assign planning and implementation data elements and planning and implementation errors.
Push back the project to implementer basket for clarifications and corrections.
Academic Credentials
Course
University
Year
Percentage/GPA
Masters in Information Assurance
Wilmington University, DE
2016
3.6
Bachelors in Pharmacy
JNTU Hyd, India
April’2012
68%
Vijaykumar
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