GANESH MALLINA Phone: 469-***-**** Email: ac3siv@r.postjobfree.com

Professional Summary

Over 9 yrs. of industry experience as a Business Analyst. The diverse experience is not limited to successful projects ranging from requirement gathering, documentation, UML diagrams, Business Intelligence, Documentation UAT and experience in HIPPA 4010 and 5010 EDI healthcare transactions such as 834270/271,835 and 837.

Good knowledge of business analysis methodologies and iterative software development lifecycle using Rational unified process. Thorough knowledge of implementing RUP in all four phases of a project.

Experience in working in domain like Healthcare and IT.

Strong work experience in tools like TOAD SQL Developer, SQL Navigator SQLPLUS.

Involved in claims adjudication process of FACETS application.

Expertise in designing and developing test plans.

Assisted QA’s and end user to understand functionality and technical requirements.

Strong knowledge on HIPAA standards, ICD9/ICD10, EDI transactions and Medicare and Medicaid Services.

Experience in working with GAP analysis between HIPPA Gateway 4010A1 and HIPPA Gateway 5010 for Medical Medicare members (MMIS).

Ability to organize document and track changes and defects using the rational clear quest and archive change request in clear case.

Good communication skills with strong analytical, qualitative, quantitative and problem-solving skills.

Expert in current industry standards such as Medicaid, Medicare, FACETS, HIPAA, EDI & other supporting applications for insurance providers and service providers.

Excellent understanding of software development life cycle.

Implemented EDI transaction 834 for medical members

Expertise in interacting with the client and the IT department and thus acted a s a facilitator between both clients and IT department to resolve conflicts through co-ordination, negotiation and interpersonal skills.

Worked on operators in PL/SQL like union, union all intersect and minus

Experience with Medicare and Medicaid (MMIS) claims processing, Medicaid billing, Medicare membership and eligibility verification and care management.

Knowledge on Relational database management system (RDBMS).

FACETS support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834 transactions.

Experience with enrollment transactions.

Expertise to design Business Requirement Specification (BRD), System Requirement Specification (SRS), User Requirement Specification (URS), Use Cases Document, Work Breakdown Document (WBD), and Requirement Traceability Matrix (RTM)

Assisted in performing various types of testing like Functional Testing, Unit testing, Integration Testing, System Testing, Performance Testing, Regression Testing, User Experience with premium payment transactions

Knowledge of X12 standards development processes

Excellent communication and writing skills and adept at facilitating walkthrough and training sessions.

Externally certified AHM250(PAHM)

CSTE, CSQA & ISTQB certified

Extensive knowledge on Healthcare domain

Expertise in Agile, V&V and Waterfall Test Methodologies.

Expertise in creating and developing Test Strategy, Test Plan, Test Cases, Test Scripts, Test Summary Reports and Defect Reports

Expertise in conducting Functional Testing, System Integration Testing, Database Testing, Regression Testing, End-To-End Testing of SAP, Mainframe and WEB Applications (Includes Java and .Net).

Strong experience on SOAP UI

Experienced in Tracking Defects and Creating reports using JIRA, Quality Center and ALM (Application Lifecycle Management)

Experience in developing UATs, Test Summary Report and Traceability Matrix

Good knowledge in Software Development Life Cycle (SDLC), Software Testing Life Cycle (STLC) and Test Methodologies

AWARDS

Received prestigious BCBS Blue Diamond Award in 2013 for SG Renewals Program management.

Received Above & Beyond award in 2014

Received Associate of the Month 2 times

Assigned as a Quality Gate Keeper for the Project in 2013

CERTIFICATIONS

CSTE Certified

AHM250 external Certified (PAHM)

ISTQB certified

CSQA – Cognizant Certified

ISTQB certified

.NET – NIIT Certified

TECHNICAL SKILLS

Technology: Facets, Informatica, Teradata, Angular JS, JavaScript

Domain / Skills: Health Care – Facets (Various Modules), EDI (83x / 27x transactions),

Edifecs, ClarEDI, ICD-10, HIPAA

Tools: ALM, Quality Center, Clear Quest, QTP, JIRA

Scripting Languages: HTML5, CSS3, JavaScript, VB Script

Operating System: Windows XP/Vista/7

Database: Oracle 11i, SQL Server, MS Access, mongo DB

Microsoft Office: Excel, Word, Power point

PROFESSIONAL EXPERIENCE

Blue Shield of California – IFP off-exchange Renewal Automation Project and Benefit Focus eExchange

Product: Facets

Client: BSC - USA

Location: Eldorado Hills, CA

Duration: May’16 – Till Date

Team Size: 4

Platform/OS Used: Windows

Languages/Tools: ALM, Quality centre, SQL, FACETS, EDI – 834 Enrollments

Description: On March 23, 2010, President Obama signed the Affordable Care Act (ACA) – a historic piece of legislation that ultimately expands healthcare coverage to 32 million uninsured and provides the security of knowing individuals will always be able to purchase quality, affordable care. The Department of Health and Human Services (HHS) will be implementing the regulations over the next four years, with the most significant impacts taking effect in 2014. Based on the new ACA federal standard provisions, in 2014 there will be two ways in which health insurance will be purchased in the Individual and Family Plan (IFP) members and Small Group (SG) markets:

Traditional Channels like today (aka “Outside” the Exchanges) such as:

oDirect Sales

oBrokers

oOnline channels

The Exchanges where individuals/families and small business will be able to purchase affordable private health insurance.

BSC has made the business decision to participate both Outside and Inside the Exchanges. Therefore, in order to implement the ACA’s requirements and prepare for the 2016 Market, (BSC) needs to:

Comply with the ACA by developing the federally mandated products to be offered to IFP members and small employer group accounts (regardless of participation in the Exchanges)

Prepare for participation in the Exchanges by developing the capability to electronically communicate product information, member eligibility, and premium billing and payment data with the state run IFP and SG[1] Exchanges

BSC’s integrated Benefits Enrollment and Claims Administration system should be ready to implement the updates needed to participate in the 2016 Market.

Responsibilities:

Responsible for collecting and analyzing Business Requirements, Process Modeling and preparation of Functional Design Specifications by employing use case scenarios, sequence diagrams.

Created use cases, activity diagrams and process diagrams using Microsoft Visio.

Gathered requirements for HIPAA 5010 migration.

Followed the Business Rules, and ensured that HIPAA compliant Rules are followed to display minimum benefit information that the Provider is required to pass on the EDI transactions.

Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates.

Validated the EDI 834-enrollment transactions.

Prepared high level and detailed system requirements documents for the application

Analyzed ICD-10 standards for 834 transactions, related to providers, payers, subscribers and other related entities.

Identified the requirements for accommodating ICD-10 standards for 834 transactions and captured these requirements to create BRD.

Participated in the walkthroughs and meetings specifically for Membership modules.

Validated the process flow for “AS IS” system and understand where exactly ICD-9 Procedural and Diagnosis Codes are used.

Translated the requirements gathered during interview with SME’s and created process flow diagram based on the requirement captured.

Identified various points of integration among the new and existing applications and required integration with other IT components.

Good experience with FACETS Claims Adjudication.

Develop ad-hoc reports on data from the other applications on claims, benefit plan, provider and financials using Business Objects Enterprise XI, Desk Intelligence, SQL Developer, MS Access and Excel, SQL, and Oracle.

Extract claims detail including ICD-10, procedure codes, diagnosis codes; member eligibility data for analysis, claim overpayment projects.

Validate data analysis and extractions against FACETS front-end system.

Manage membership analysis; FACETS claims analysis and ad-hoc reports.

Compile SQL Queries to validate the data integration between the various Database tables.

Involved in mapping data from different EDI files onto database using different routing transformations.

Performed gap analysis for migration of HIPAA transactions from 4010 standard versions to 5010 standard versions.

Work together with the architects and team responsible for supporting rules processing tools during the project to assist with the required support.

Work closely with the business team, development team and the Quality Assurance team to ensure that desired functionalities have been achieved by the application

Assisted the project with Change requests and held responsible for weekly changes to the applications. Maintained and recorded the ticket numbers for request changes on CR manager tool.

Involved in testing Facets Member/Subscriber, Billing, Medical Plan, Dental Plan modules.

Provide business and technical suggestions and recommendations during the project life cycle.

Blue Shield of California – Small Group Renewals and HMO

Product: Facets – SG

Client: BSC - USA

Location: Hyderabad, India

Duration: June’14 – Oct’15

Team Size: 20

Platform/OS Used: Windows

Languages/Tools: ALM, Quality centre, SQL, FACETS – Claims & Membership

Description:

The Small Group renewals and HMO project will provide the ability to:

Build and implement products

Mid / Large HMO, Mid / Large, Mid / Large Access Baja HMO & Specialty Benefits products related to Medical HMO membership

Provide Heath Care Services programs and optional buy up programs

Support health care reform requirements that are not already built in support of previous releases

Integrate with existing trading partners and systems, including:

oArgus (retail pharmacy vendor) (involves interfaces RIC 15,24)

Support implementation and verification of HMO Argus coverage codes in BSBS (Benefit Summary)

oMagellan Behavioral Health - behavioral health vendor

oDental Benefit Providers (DBP) - dental vendor

oMedical Eye Services (MESVision) -vision vendor

oAmerican Specialty Health Plans - chiro & chiro/acu services for HMO & POS

Responsibilities:

Worked in Enrollment, renewals and Claims module for HMO project. This includes – Configuration testing, ITS claims, and External systems such as DST, Argus, UM etc…

Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus for BRD and FRD and business docs.

Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.

Involved in the testing of web portal of New MMIS system

Acted as a liaison and conducted meetings, JAD sessions and presentations with the teams

Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.

Worked on the existing mainframe system, documented the system requirements and came up with Use Cases from the analysis.

Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.

Assisted in Regression Test, System Test, and UAT.

Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS

Blue Shield of California Operations QA

Client: BSC - USA

Location: Hyderabad, India

Duration: April’13 – May’14

Team Size: 15

Application / Tools: Facets, QC, ALM, SQL server

Description:

Operations is to validate the post productions service requests and defects with existing business impact w.r.t the new LOBs implemented in Shield Advance. The project delivery timelines are highly critical. Shield advance is a program initiated by the BSC client to render Health Insurance to the people of California. BSC ties up with strategic Vendors to provide Healthcare services to its members as a part of which it frequently interacts with those Vendors for exchange of the Health insurance information of its members.

Responsibilities:

Collected weekly status reports to ensure that all deliverables are met on time and on schedule.

Conducted JAD session with management, senior management executives, and other stakeholders for open and pending issues on the development of the project.

Created Use Cases from the list of requirements and prepared use case diagrams using Rational Rose.

Conducted Web Meetings with Off-Shore team members to ensure that everybody is on the same page.

Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter, to meet and exceed HIPAA requirements set forth by the federal government.

Performed EDI activities that comply with government reporting requirements and standards.

Overseeing and maintaining the EDI inquiry problem database including the evaluation of problems or issues through resolution.

Perform analysis on EDI 270/271,837, ANSI-12XN etc. HIPPA code sets for Medicaid health plan members.

Assisted in tailoring the views and applets for opportunities, accounts and contacts etc., as per the client requirements.

Worked on FACETS up-gradation project (from version 4.41 to 4.47)

Validated the member information of different groups against FACETS during the batch enrollment.

Set up the subscriber/member Group, Sub Group, Plan, Product etc. using GUI application and help of batch process.

Entering Claims and Customer Service Tasks into the FACETS.

Further analysis of the requirements was performed using rational rose through the use of sequence, entity relationship diagram and class diagram.

Conducting regular audits of EDI transaction of Medicaid members to determine accuracy and areas for improvement and maintaining EDI maps and business rules for HIPPA validation software.

Responsible for creating and reviewing business requirements, functional specification project schedules, documentation and test plans.

Coordinated with project managers to resolve risk issues and ensure compliance of security system -related to the HIPPA.

Assisted testing teams in creating test scripts and UAT to check the security of the CRM system to improve stability and help better customer satisfaction.

Closely interacted with designers and software developers to understand application functionality, navigational flow and updated them about end user sentiments.

Assisted in the improvement of the CRM system of the organization by carrying out JAD Sessions to enhance usability and functionality of the system.

Extracted the Business Requirements from the Business Users and documented it for the developers following the HIPAA guidelines by conducting JAD sessions and Interviews.

Worked Extensively with Inbound 837 I and 837 P and 835 (Out bounds) claims processing systems.

Used Query Analyzer, Execution Plan to optimize SQL Queries.

Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.

Custom SIT & Sys-date Batch Remediation

Product: Facets

Client: BSC - USA

Location: Hyderabad, India

Duration: Apr’12 – Mar’13

Team Size: 3

Platform/OS Used: Windows

Languages/Tools: Web Services, SQL

Description:

Custom project is to validate the data as per the custom changes configured w.r.t Blue Shield of California business needs (Primarily Performance Guarantee, Tenthly Billing logic) based on the functionality and requirement. As part of this project, Members will be loaded into Facets using 834 EDI files and EC+ Portal. Once enrollment is completed, we will validate if the custom changes are working as expected. Once data is loaded into facets, will also check that all the downstream applications like ID cards and bills are generated successfully.

As part Sys-date batch remediation project, the validation was done on the data collection period of all the tidal batch processes (Approx 90 interfaces- Both inbound and outbound) which will collect data based on the functionality and requirement.

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Responsibilities:

Maintained clear understanding of project goals among stakeholders by conducting walkthroughs and meetings involving various leads from BA, Development, QA and Technical Support teams.

Facilitated Joint Application Development (JAD) Sessions for communication and managed Net Meetings.

Conducted meeting with the EDI team and other stakeholders team members to discuss the requirements.

Prepared gap analysis document for each transaction.

Analyzed “AS IS” and “TO BE” scenarios, designed new process flows and documented the business process and various business scenarios.

Wrote use cases and relevant UML diagrams such as Use Cases, Activity and Sequence diagrams.

Wrote high level and low level business requirements for the project.

Developed and conducted statewide HIPAA 5010 and ICD-10 awareness program for all AMFC staff in the Philadelphia Campus.

Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA 5010 requirements.

Presented the process improvement solutions to the client, performed Project Management Office (PMO) activities.

Worked closely with the business team, development team and the quality assurance team to ensure that requirements are understood as intended in order to achieve the desired output.

Participating in all facets of the standard project life cycle and ensured smooth transition of projects to production support

National Health Services (NHS) - LORENZO – Release 1 & Release 2

Client: NHS - UK

Location: Hyderabad, India

Duration: Jun’09- Mar’12

Team Size: 40

Platform/OS Used: Windows

Languages/Tools: .Net, Sql Server, Quality centre, Clear Quest, Ensemble - HL7

Description:

The National Health Service (NHS) is the publicly funded health care system of England which is responsible for government’s services with a cost of £2bn by product called Lorenzo which is developed collaboratively by CSC and iSOFT. NPfIT is said by the NHS CFH agency to be "the world's biggest civil information technology program" and largest civilian IT project for patients and to connect 30,000 General practitioners to 300 hospitals. The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry and other support services. The costs of running the NHS (est. £104 billion in 2007-8) are met directly from general taxation.

Lorenzo is the product for NHS Connecting for Health Systems and Service Delivery software suite to deal with patient registration, support the recording, sharing, exchange and comparison of data and information across and within the NHS and patients will also have access to their records online.

As a Phase1 there are Clinics, PAS and Primary Care along with Maternity and Theatres

As Phase2 the Lorenzo is delivered as LE2.1 and LE2.2 for Clinics, Orders, Results, Discharge Summary, Waiting List, Outpatient, ADT, Mental Health Administration, A&E and Caseload Management

LE3.5 consists of PMI Update, Orders, Results, Discharge Summary, Waiting List, Outpatient, ADT, Prescribing, LORENZO Primary Care, Clinical Documentation, and Patient mgmt, Mental Health Admin, Community, Day Care, A&E, Clinical Services, Maternity, Caseload Management and Theatre Management.

Responsibilities:

Leads joint application design requirements and solution sessions across IT teams

Maintain and develops documentation as part of defect resolution and change management.

Perform peer review of design documentation

Provides subject matter expertise to help identify impacts of system design

Demonstrates s high level understanding of how health insurance business works

Perform source to target mapping efforts for multiple health care records to ensure source system data is properly matched/identified for further processing.

Work with data architects, data modelers and developers to ensure accuracy with data mapping. Source to target mapping(STTM) expertise.

Assure the integrity of project data, including data extraction, storage, manipulation, processing and analysis.

Perform data profiling and detailed data analysis of source systems and target solutions.

Perform peer review of design documentation.

Possesses and applies a broad range of expertise of principles, practices and procedures of particular business function to the completion of complex assignments.

Med Advantage

Client: Med Advantage

Location: Hyderabad, India’

Duration: Nov’08- May’09

Team Size: 4

Platform/OS Used: Windows

Languages/Tools: Java, Sql Server, Quality centre, Clear Quest,

Description:

Med Advantage provides credentialing verification services to Fortune 500 companies, national HMO's and locally-owned managed care organizations. This process employs various alternatives (Web access, on-demand fax service as well as traditional credentialing service) to easily integrate our data verification services into your business environment. Med Advantage is ideal for small or large corporations with different environments serving a variety of credentialing needs. It has different credentialing process such as Provider’s application is received from Client or directly from Provider, Information is entered into Med Advantage’s credentialing system, Appropriate letters and database inquiries are generated to verify the provider’s credentials, Verifications are updated in the credentialing database, All original documentation and verifications are sent to the client, as well as, electronic extractions as requested.

Responsibilities

Understanding the Business requirements and case study.

Preparing Test design and creating test data.

Executing test cases.

Performed System Integration Testing for IFP SIT Project.

Schedule the Batch jobs/Interface jobs in Tidal application

Preparation of the KT document for the new requirements

Regular interactions and reporting the defects in QC.

Updating the Status to Senior Management.

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