Customer Service Insurance
Resume:
Shally Singh Risam *******@**********.***
SUMMARY PROFILE:
Having good 8+ years of professional System Analyst and BA experience.
Strong analytic skills. Excellent written and verbal communication skills.
Good interaction with developers, managers and team members to coordinate job tasks
Excellent business partner interaction and facilitation skills. Strong organizational and process adherence skills.
Strong problem solving capabilities with Good communication skills with a proven track record of success.
Demonstrated ability to work as a team player as well as an Individual.
In IT Software in the field Software testing& quality with proficiency in Health Care Nasco Processing System.
Involved in analysis, and executing the Test Cases. Tested many scenarios for New Group implementation.
Good working experience on NASCO – NPS system.
Good Experience working with NASCO – Applications such as – HIQK, HEHK, HSSK, HRBK, HRRK, HURK, HSSK, TPOL, PDM and EFDE.
Tested local groups, small groups for acknowledgements and confirmations.
Good knowledge on HIPAA EDI transactions 834, 835, 837, 270, 271.
Extensively involved in Unit Testing, System Testing, Integration Testing, User acceptance Testing, Regression Testing and Quality Control
Key BA Skills: Requirements gathering, GAP Analysis, Use Cases, Wire-Frames, RUP, JAD Sessions, Traceability Matrix
Evaluate and define system scope and objectives based on user needs and thorough understanding of business processes.
Analyzed the Benefit / Procedure file to determine the specific POS/TOS conditions for Column routing using HURK.
Experience in analyzing and requirements gathering and writing system functional specifications including use cases.
Excellent in Developing and evaluating business process models.
Proven success as a data analyst through the years, providing a well-balanced understanding of business relationships, business requirements, and technical solutions.
Expertise in UML (class diagrams, object diagrams, GAP Analysis, use case diagrams, state diagrams, sequence diagrams and activity diagrams) as a data analysis methodology for application functionality designs using IBM’s Rational Rose.
TECHNICAL SKILLS
Requirement/Application Management Tools: Rational Requisite Pro, MS Office Suite, MS-Project, Share point Portal Server 2003/2007, Enterprise Architect, Knowledge of DOORS.
Repository Management: Rational ClearCase, SharePoint
Methodologies: Waterfall, Spiral, Rational Unified Process (RUP), Agile, Capability Maturity Models (CMM).
Relational Databases: SQL Server 2005/2000, Oracle 10g/9i/8i, MS Access.
Operating Systems: Windows NT/2000/2003/XP/Vista, UNIX.
Quality Assurance Tools: Test Director, Quick Test Pro, Quality Center
Languages: SQL, PL/SQL and T-SQL, HTML, XML
Reporting Tools: Business Objects,
EXPERIENCE
Blue Cross Blue Shield Michigan March 2014 – May2017
Analyze the PCR (policy change request) from Medical Affairs.
Perform Unit Testing and Acceptance Testing in Model Office and Post Production Testing in Production.
Look for Logic in Benefit File, GENO Tables, Flex Plan Rules and Procedure File.
Create CSRs (Customer Service Request) using CSR Financial Tool and write CSRs in PDM.
Present and explain the design changes to Quality Release Management for approval.
Using Change manager Tool to send request to File Maintenance team for GENO Table update.
Procedure File Update using MDSS Procedure File Request Form.
Perform Validations in Model office and Production environments.
Helped in collaborating billing with client database and simplifying the billing process.
Performed GAP and Risk analysis of existing system and evaluated benefits of new system.
Facilitated the weekly meetings with the review teams to continuously improve the QA process for the application development.
Worked with QA team to design test plan and test cases for User Acceptance Testing (UAT).
Pull EOBs, Vouchers and 835 Using HCBO and Personix for Validations in addition to setting up Benchmark scenario claims.
Work on all change manger Activities.
QRM for all Benefits changes.
Blue Cross Blue Shield HORIZON NJ Nov 2013- Feb 2014
UAT ICD 10 System Analyst
BPM UAT Team to perform the Claims User Acceptance Testing from a business perspective.
Created Ids and assigned access to them.
Added the required access to the appropriate person.
Test the scenario to see if they pass or fail.
The goal of this document is to define and confirm the activities, develop a project plan and identify the resources required to successfully complete UAT for claims processing component of the BPM initiative
Access Claims: UAT Test team would validate that Research station pended claims can be accessed via the new BPM application.
Assign Claims: UAT Test team would verify that all claims are assigned to Service area team. Team would validate
Total claims pended in RS = Total Assigned + Unassigned+ Conflict
Reassign Claims: UAT Test team would test the ability of users to manually reassign claims to different area
Business Rules: UAT Test team would validate that the production claims picked up for testing are being routed based on Business Rules set-up.
Reports: UAT Team would test user’s ability to pull claims reports for one or multiple areas
Test Deliverables Sign-off
Worked on CPL Defects
Blue Cross Blue Shield Michigan May 2011- Sept 2013
Analyze the PCR (policy change request) from Medical Affairs.
Perform Unit Testing and Acceptance Testing in Model Office and Post Production Testing in Production.
Look for Logic in Benefit File, GENO Tables, Flex Plan Rules and Procedure File.
Create CSRs (Customer Service Request) using CSR Financial Tool and write CSRs in PDM.
Present and explain the design changes to Quality Release Management for approval.
Using Change manager Tool to send request to File Maintenance team for GENO Table update.
Procedure File Update using MDSS Procedure File Request Form.
Perform Validations in Model office and Production environments.
Pull EOBs, Vouchers and 835 Using HCBO and Personix for Validations in addition to setting up Benchmark scenario claims.
Send communication Alert using Change Manager Tool.
Document result in close down packet and update share drive with all permit information.
Use BF test suit to pull claims for testing purpose.
Blue Cross Blue Shield NJ January 2010 – Nov 2010
Benefit File Analyst
Project: New Group Testing and Implementation
Benefit changes
PIDS
Roles and Responsibilities
Performed complete testing on the NPS system – from preparation of test case documents, identification and documentation of the functional test scenarios, creation of test claim data and involved in preparing test case documents
Conducted test cases for mental health, substance abuse, outpatient and inpatient scenarios
Part of the testing team for the New Group Implementation testing for numerous groups
Conducted testing for benefit changes - based on the BIFs for the corporate Groups of Horizon
Conducted O&P Mandate Testing based on the guidelines of the O&P Mandate project – which involved the benefit changes for the Orthotics and Prosthetics columns
Extensive knowledge of HIQK, HEHK, HRRK, HURK, HRBK, TPOL, procedure and diagnosis files
Analyzed and completed coding on HRBK and inquires that are performed on HIQK transactions, BS, LS, substring, particular, column coding, sub particulars
Analyzed, assigned, coded, and copied the benefit with new benefit strings, particulars and sub particulars
Worked on the classification of the fee strings for all groups impacted
Involved in weekly issue meetings with the team and team leads
Extensive knowledge of HIQK-HEHK-HRRK-HURK-TPOL, benefit file mnemonics, procedure and diagnosis file
Worked on production issues
Worked on Clear Quest
Business Analyst, Metlife, Boston, MA Sept 2008 – Dec 2009
MetLife Insurance is one of the biggest providers of Life Insurance in US. It has wider verity of business in Individual and group insurance, Disability Insurance, Long Term Care, Auto and home. MetLife insurance (Individual Business) uses a web application CAS for underwriting life insurance policy. This application is always undergoing with various enhancement/improvement every 3-4 months. CAS also interacts with various other vendor application and interfaces.
Worked to BRIDGE the gaps between IT and Business Client.
Conducted JAD sessions with both business and technical teams (Stakeholders, SME’s).
Developed prototype of the application with additional features as per requirements.
Actively participated in designing of Mock up screens using Visio.
Helped in collaborating billing with client database and simplifying the billing process.
Performed GAP and Risk analysis of existing system and evaluated benefits of new system.
Facilitated the weekly meetings with the review teams to continuously improve the QA process for the application development.
Worked with QA team to design test plan and test cases for User Acceptance Testing (UAT).
Business Analyst, MSSPL NEW DELHI INDIA Mar 2007 – May 2008
Mystery Shopping audit program is a tool to measure quality of retail service. It is an independent and constant examination of the ‘real’ practices being followed at customer interaction points and what are your customers really thinking about your products and services? It helps in evaluating the practices in relation to defined standard requirements and help companies to achieve r4xsconsistency as well as continual improvement in their customer delivery models, standards, procedures
Develop reports on the audits done by the auditors gather information regarding the particular topic.
Collect all the information about the project and interact with the auditor and collect all information.
Interaction and information from different sources of information.
Interact with the product owner to gather requirements for new project.
Interact with clients and gather and document user requirements.
Providing total customer satisfaction with all the formalities and legalities involved.
How to deal with pressure of matching up with the expectation of the company.
Establish good work relationship and work team promotion and communication and suggestion on participation.
Provide quote and timeline to clients
Maintain project schedules in MS Project
Maintain project issue lists.
Reviewed test scripts and objectives and, coordinated, managed the execution of the user acceptance testing.
EDUCATION
B.B.A, University Of Kashmir Jammu & Kashmir India.
M.B.A University of Madurai New Delhi India
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