Toral Joshi

ac77lg@r.postjobfree.com

740-***-****

PROFESSIONAL SUMMARY:

Business Analyst with 5 years of experience in health domain with a wide-ranging knowledge of all aspects of Software Development Life Cycle (SDLC)

Experience working with Medicaid eligibility, benefits policy, budget management, long term care administration

Maintained project documentation and coordinated team efforts to successfully complete projects.

Documented specifications based on user scenarios, requirements and input from business, wrote functional specifications for software applications.

Experience with coordination of benefits

Profound Knowledge of Rational Unified Process (RUP) methodology, Use Cases,

Responsible for gathering MS CRM information for the customers to create reports forbusiness users and stakeholders.

Extensive experience in gathering business requirements, business processes, identifying risks, GAP analysis and UML modeling.

Knowledge and experience including HIPPA, Facets and QNXT.

Knowledge with end to end process in Member Management, Provider Management.

Developed expertise in claims processing and direct clearinghouse for claim processing and billing to insurances companies nationwide all on a SQL backend.

Managing reporting, analysis and decision-making for a change request using tools like ClearQuest and Excel.

Build and maintain strong relationships with business partners, customers, technology teams and Data Management team to build Business Intelligence solutions.

Experience in conducting Joint application development (JAD) sessions for gathering requirements, and Rapid application development (RAD) sessions to converge early toward a design acceptable to customer.

Validated all kinds of professional and institutional claims with the related data in the reference subsystem

Validated dental claims with the related data in the reference subsystem

Extensive knowledge of Medical Management Information Systems (MMIS), National Provider Identification (NPI), Health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI), Health Level -7 (HL7), HIX (Health Information Exchange), EMR/EHR, Health Care Reform and Patient Protection and Affordable Care Act (PPACA).

Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277/997(X12 Standards) processes of Medical Claims Industry from the Provider/Payer side

Knowledge of health information and health care services regulatory environment including HIPAA, Medicaid/Medicare, EDI and XML.

Experience in creating workbooks and dashboards using Tableau that includes tools like Tableau Desktop, Tableau Server and Tableau Reader

Excellent understanding of Business Requirements Gathering, Translating Requirements into Specifications and Application Design.

Developed dash boards with rich Graphic visualizations, Drill Down and Drop-down menu options, parameterized using Tableau.

Knowledge and experience including QNXT, Facets, NASCO, ICD -9 and ICD-10 as a configuration analyst.

Experienced in executing test cases using HP QTP, logging them and making sure they are fixed before release.

Strong HIPAA EDI 4010 and 5010 with ICD9 and ICD10, analysis & compliance experience from, payers, providers and exchanges perspective, with primary focus on Coordination of benefits

Capable of forming and maintaining positive and productive working relationships in internal, external, independent, and team environments.

Experienced in developing test plans and test strategy and handling UAT sessions.

Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicare, and implementation of HIPAA key EDI (ANSI X12) transactions.

Excellent interpersonal communication skills and quick to adapt to new environments with strong problem solving and trouble shooting skills.

TOOLS AND SKILLS:

Platforms: Windows, Mainframe

Testing tools: Trizetto FACETS 5.01, QNXT, HP Quick Test Professional

Change Management Tools: Rational,ClearQuest, Test Director, HP Mercury Quality

Office Tools: Project, MS Office, MS Visio

Database: MS SQL Server, MS Access, Oracle

Bug Reporting Tools: Quality Center, QTP

PROFESSIONAL EXPERIENCE:

Family Health Network, Chicago – Illinois June 2017 to November 2018

BusinessAnalyst

Family health network is a not-for-profit provider sponsored HMO. It is directed by local health care providers. Vida claim is used at FHN for claims processing and care management. As a Business System Analyst I was involved in gathering requirements for their claim system (vida claim). Reviewed payments in payer compass for all their hospital claims.

Responsibilities:

Executed UAT Test cases and Test scripts from the requirements- Functional, Business workflow

Executed the process flows through the application step by-step and demonstrate that all participants understand how the system execute the process

Ability to understand test cases, test scripts for various claims scenarios & modules

Running the test cases and it scripts and executing them thoroughly with pass/fail status and documenting defects

Entering defects for failed test cases and assign the defects to appropriate developers. Re running failed tests

Re running UAT test of the application once the defects are fixed and passing the test cases

Day-to-day management of various testing scenarios against daily Target

Tracked completion of tests against the plan and report progress

Reported the overall progress of team’s progress to FHN

Coordinated the resolution of issues/defects with FHN Development team & testing team

Provided answers to questions relating to policy and business processes within their specific tracks

Alert the FHN Business/IT team of changes that potentially impact test cases or the testing effort in general or identification of Incorrect test scenarios

Provided the process flow, scenario, gaps and associated recommendations

Experience in Validating member eligibility and eligibility inquiry in the Claims application

Experience in Medical, Hospital, Pharmacy Plan changes from one plan to other plan with in Group, subgroup, class combinations

Experience with COB (coordination of benefits) testing of claims status

Well experienced in benefit coding of different products for various plans

Calculated co-pay, coinsurance, adding single tier, multi-tier for different products within a plan

Compared plan and product details in medical module, and reviewing the benefit summary, co-pay and coinsurance for various codes example.

Understand claims Pricing-Serve as a resource for operations staff on contracting and pricing methodologies, complex contract interpretation, claims procedures and other repricing related functions for HCFA s and UB s.

Experience in UAT testing of core application and custom modules as needed

Claims validation in core application which includes claims pending status, member status, etc.

Ensured all User Acceptance testing is conducted and documented according to standards against Daily Targets

Substantial report development experience utilizing SQL Server Reporting Services (SSRS).

Coordinated and participate in group and end user test planning; including; that tests, evaluates, and validates new system functionality

Developed summary reports to document test results so information can be shared with FHN Business Owner and IT development team

Ensured operational quality by rejecting system changes that do not function properly and meet user expectations

Hands on experience in Claims processing/Resolution

Experience in Healthcare Benefit Configuration: Membership, Benefits, Provider contracts, Pricing, Medical reviews, Referral authorizations.

Pulled out various reports using SQL and submitted to the business users on timely basis with the project updates.

Code reviewed, Fee schedules, UAT testing.

Proficiency in medical terminology, medical coding (CPT4, ICD9, and HCPCS), provider contract concepts and common claims processing/resolution practices.

Required Prior UAT testing or equivalent claim related testing experience.

Required Previous repricing or claim adjudication experience

Responsible for Data Extraction, Data Compilation, Data Analysis, Data Manipulation and Data Validation using SQL queries in a MS SQL Server environment.

Generated XML documents using the XML Output Stage.

Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.

Environment: UAT, MS office, MS Visio, Quality Center, Water Fall, JIRA

Affinity Health Plan, Bronx, NY June 2016 to June 2017

Business Analyst

As a Business Analyst I was involved in the implementation of Facets administrative system, a new core system built by with updated technology to allow for more efficient claims processing, membership enrollment and provider data maintenance & getting access to customer records. X12 EDI and HIPAA standards were followed thorough the project.

Responsibilities:

Performed forward and backward mapping between the two standards and documented the required changes.

Conducted meetings, Joint Application Development (JAD) sessions and interviews with the business users to gather requirements.

Validated documentation and validations in compliance with Affordable Care Act (ACA).

Involved in the processing of the claims and then sharing the test results with the business according to test acceptance criteria during their UAT phase.

Independently created Business Requirement Document (BRD) for the whole project.

Created use case diagrams, activity diagrams, and flow charts to depict the interaction between the various actors and the system.

Implemented SDLC which included requirements specifications, design, analysis and testing.

Worked on the database analysis part by helping the technical team in identifying the data sources required for the application and coordination with the IT team in migration of the data within the databases.

Developed non-functional requirements and documented them to be presented to the technical team

Helped the QA team in writing the Test Plan and conducting the quality assurance phase.

Worked with the QA team in testing the application using HP QTP.

Logged application bugs and was involved in all stages of the bug life cycle.

Helped developers and programmers with unit testing and providing test coverage of the application

Dealt with Project lead, stakeholder and end users regarding any issues encountered during the project.

Developed non-functional requirements and documented them to be presented to the technical team

Helped the QA team in writing the Test Plan and conducting the quality assurance phase.

Involved in database interactions for retrieving appropriate data and generation of output file and reports.

Involved in GAP analysis both at the time of requirement gathering and later after development with the Testing team to identify areas and possible scenarios that might have been overlooked.

Involved in back end testing using SQL Queries on Microsoft SQL Server 2005/2008.

Worked extensively in creating dashboards using Tableau Desktop and published them on Tableau Server. Involved in the administrative tasks of Tableau server like installations, upgrades, user & user groups creation and set up of security features

Tableau dashboard layouts were effectively used to give interactive visual analysis experience to the end user.

Facilitated collection of functional requirements from system users and preparation of functional specification documents that provided appropriate scope of work for technical team to develop prototype and overall system.

Additional responsibilities included mapping the requirements in Caliber to the Test Cases and Scenarios in Quality Center.

Involved in identifying dummy data for the testing scenarios for the QA team

Environment: MMIS, UAT, MS office, MS Visio, C, C++, Java, Quality Center, Tableau,SDLC, Facets, Used Cases

Harmony Information System, Reston, VA Sept 2013 to May 2016

Business Analyst

I worked as a Business Data Analyst at Harmony Information Systems. Harmony was working with EDS for the State Of Virginia. The objective of the project is reverse engineering the technical documents and standardizing them to meet the HIPAA Compliance Standards and getting them insync and up to date with the business rules using the Microsoft BizTalk Server along with testing the application manually from the backend. I worked extensively on their Claims processing, which was a part of the Harmony Financial Suite.

Responsibilities:

Created documents that incorporated both the technical and functional details.

Involved in standardizing the documents to meet the HIPAA Compliance Standards.

Involved in creating documents and diagrams for Claims Processing and Claims Management according to the HIPAA Compliance Standards for Claims Processing.

Created Use Cases that defined the role of users who receive claims, users who process claims and users who adjudicate claims. Used MS Visio to develop UML diagrams

Conducted and participated in walkthroughs to generate consensus, maintaining quality and resolve issues among different stakeholders in the SDLC.

Involved in updating and/or reworking previous documentation on their Claims Management System to get them in sync and up to date with their current new system in place.

Involved in creating test cases and test documents based on the technical documents I created.

Involved in manually testing the application from the backend to carry out data validation.

Attended Joint Application Mapping (JAM) Sessions with my team to map the business needs.

Used requirement elicitation techniques such as JAD Sessions and Document Analysis to gather information regarding the application from the SME

Maintained open and clear communication with the team on change requests.

Involved in weekly status meetings for updates.

Ensured that all Entrance and Exit criteria were properly met.

Hosted all the documents in Share Point and assigned them to the requisite individuals for review along with using Share Point as a document management tool.

Performed backend testing to check the system data integrity for insert, update, delete and retrieve transactions by writing complex SQL queries including joins, group by, having clause etc.

Created UI Documents as supporting documents for the Business Requirements Documents.

Involved in Data Flow/Business Process Diagrams to illustrate the flow, input and output of data.

Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.

Used Mercury Quality Center as our bug reporting and defect-tracking tool.

Performed manual testing of the functional items by checking a summary of all claims entered and submitted.

Environment: MMIS, UAT, MS office, MS Visio, C, C++, Java, Quality Center, Water Fall, JIRA

EDUCATION:

Bachelor in Commerce

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