Health Insurance Service

Hareesh Lingam

Sr. Business Analyst

PROFESSIONAL SUMMARY

? Around 10 years of IT experience with US Healthcare Payer experience as Business Analyst while

working for various US Healthcare Payer Clients

? Well versed with Requirement gathering, Requirement Management, Use Case writing, Use case

diagrams/modeling and other Business Analysis skills/methodologies in general

? Experience in analyzing AS-IS business processes by communicating with Client stake holders at

various levels and coming up with TO-BE state along with necessary aids like business process

flows, data flows, Gap and Impact analysis

? Played a vital role throughout several project life cycles by understanding and representing

stakeholder’s need, documenting, prioritizing and organizing the requirements for IT systems and

communicating them to the entire team along with an active role in performing/managing functional

testing of the information system being developed

? Experience in project scoping, estimating resource requirement and business case preparation

? Adept in development and documentation of business requirements (BRD), functional specifications

(FSD),Test artifacts, Requirement Traceability Metrics and other necessary documents in SDLC

phases

? Recognized as a hands-on, pro-active troubleshooter, who can rapidly identify business problems,

formulate strategic plans, initiate change and assist to implement new process in challenging and

diverse environments

? In-depth understanding of Software Development Life Cycle (SDLC) using Waterfall, Rational Unified

Process (RUP) and Agile methodologies

? Experience in design and development of test plans, test case scenarios, test cases and extensive

participation in system testing and UAT

? Facilitated and participated in Joint Application Development (JAD) sessions, user workshops,

interviews, conference calls and white board sessions to keep executive staff and the team members

apprised of goals, project status, and resolving issues.

? Proven ability to co-ordinate a diverse set of Client business users/stake holders to develop cohesive

and streamlined requirements, documentation and user acceptance criteria to achieve the project

objective on time and in budget

? Designing and executing test plans, test scripts, tracking defects and getting them resolved to ensure

that business requirements and functional specifications are tested and fulfilled

? Proficient in MS Office Suite, MS Visio, MS SharePoint, HP Quality Center, HP Service Manager and

Application Lifecycle Management (ALM)

? Adept in data analysis, GUI designs, customer management, team management, problem-resolving

skills, conflict management skills, people management skills and excellent knowledge of soft skills,

writing skills and oral communication.

? AHIP certified US Health Insurance professional with PAHM designation

? Hands on experience in all the Healthcare EDI Transactions (Expertise in 837, 270/271, 276/277,

27,820, 834 and 835) and worked in end to end implementation of HIPAA 5010 program for one of the

largest Blues in the US

? Strong understanding of processes and operations of US Health Insurance Industry including current

Regulations like Healthcare Reform, Health Insurance Exchanges, HIPAA 5010, and ICD 10 etc

Skills/Tools

? UML, Rational Requisite Pro, Oracle 8i/9i/10g, SQL Server 2000/2005/2008, HP Quality Center, HP

Service Manager, Application Life cycle Management (ALM),SQL, Mainframe, MS Office Suite

2010/2007/2003 (Excel, Word, PowerPoint, Outlook, Project, Visio), Windows CE/NT/2000/XP,

SharePoint 2010 and IBM Data stage (ETL)

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Email: *******@*****.***

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PROFESSIONAL EXPERIENCE

Special Risk Operations (SRO), Cigna

Group Claims Management and Financial Integration May 2013 – Till

Date

Sr. Business Analyst

Philadelphia, PA

SRO was developed to process Life, Disability and medical claims. Main inputs to SRO are Claims from

ACCLAIM application system and CICS online transactions entered by SRO users during the day . SRO is

being replaced by GCMFI FINEOS workbench due to inherent risks associate with legacy system.

Responsibilities:

? Gathering and managing Business Requirements, Requirement Elicitation, Gap and Impact Analysis,

providing high level design solutions, and delivering System Requirements by closely working with

SME’s and Business stakeholders

? Analyzing business requirements and current system behavior and collaborating to create system

design specification documents including functional specifications, system use cases, mock-ups,

design models, Business process flows, Data flow diagrams

? Actively involved in JAD sessions, Conference calls and Business Interviews.

? Responsible for documenting Use Cases.

? Supporting software implementation and system enhancements

? Preparing software system design and doing system analysis for defect prioritization and fixes

? Prepared test scenarios and participated in functional testing

? Coordinated with the users in performing User Acceptance Testing

? Facilitated Retrospective meetings(After Action Review) with the users after the application went live with the

users to discuss what went right and what could have been better

Environment: Mainframes, IBM DB2, CICS, Acclaim, Fineos, SQL Server, Oracle, IBM Data Stage (ETL), HP

Quality Center, ALM, HPSM and MS Visio

PROCLAIM, Claim Adjudication, Cigna October 2012 – April 2013

Sr. Business Analyst

Philadelphia, PA

Proclaim is an auto adjudication engine enables faster and consistent processing of PPO claims .

Responsibilities:

? Responsible for impact analysis document (Analyzing service requests for ICD 9 to ICD 10)

? Actively involved in JAD sessions, Conference calls and Business Interviews.

? Worked on transactions such as Enrollment, Claims, Medicaid, Medicare, Benefits Affected and HIPAA

complaint security issues.

? Responsible for documenting Use Cases from scratch as well as making changes to the existing Use Cases

? Final Business Requirement document that would help IT to perform the necessary changes as

approved by the Business area

? Attend, coordinate and lead weekly and ad-hoc project/operational meetings to discuss progress of

the deliverables and ensure timely completion

? Assisted Testers in writing Test Cases and Test Plans

Environment: Mainframes, IBM DB2, MS Visio

Hareesh Lingam

Sr. Business Analyst

Test Management, Transaction Management

Product Development Jul 2011 – Sep 2012

Business Analyst

Seattle, WA

Test Management enables health plans to easily create, edit and manage test data and results. It includes

a pre-built test data repository and capability to derive test data from customer production transactions.

Business analysts and testers can easily create or modify test data using intuitive editing screens

Transaction management enables healthcare organizations to use transactional data in an efficient

manner. Operational efficiency will be improved by providing end to end visibility, identify deviation easily

and facilitates communication between trading partners to meet service level agreement

Responsibilities:

? Business Requirement Documentation, Mapping EDI fields to common format for 270, 276, 278, 820,

834 and 835 Develop mock screens with user experience team, functional testing and Handling

product enhancements requests

? Participate in design discussions

? Cascading requirements to the development team and effectively communicate the functionality

inherited in all the requirements in an Agile environment

? Managing change requests by analysing the impact, value addition, effort estimates, time frame to

achieve functionality wish list facilitating Business Users to take appropriate decision

? Prepare Test Plan, test strategy and test cases for the thorough Functional testing in specified Testing

Environment and executing test case as pre-UAT phase

? Preparing data for client demos, participation in product trainings and product documentation

? Supporting implementation and configuration of products

? Training development team on Health insurance business

Environment: Grails framework (Open source) SQL Server, Oracle, HP Quality Center and MS Visio

Gaps in Care

BCBS Louisiana Apr 2011 – Jun 2011

Business Analyst

The current process in place for reaching out to Health plan members who are believed, based on the

claims data, to have not completed/undergone one or more of the identified preventative care activities is

largely a manual concept. The objective of the project is to develop a system infrastructure to facilitate the

quarterly generation of outbound notices to health insurance members who have been identified as

having potential gaps in their health care. The goal is to design member intervention rules and tracking

mechanism to enable more consistent, repeatable and sustainable Gaps in Care (GIC) outreach effort

Responsibilities:

? Understanding the current manual system with the help of high level requirements, client meetings

and other discussions

? Conducting requirement gathering sessions and documenting requirement in the client provided

template and getting sign off

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? Translating the functional requirement into use case language and process flow to assist technical

team to come up with required architecture

? Performing impact analysis of all the integrated system as a result of changes in required database

? Identifying database requirement for every kind of input for the development of GIC database

? Acting as SPOC for all the functional queries from development and testing team and getting all the

ambiguities resolved by having discussion with Client

? Preparing Process and Data flow diagram which in turn would be used as an input to the creation of

functional architecture

? Preparation of Requirement Traceability Metrics, Test scenarios and test cases

Environment: BizTalk, FACETS, SQL server, SSRS. MS Share point Portal and MS Visio

HIPAA 5010 Implementation

BCBS Louisiana Oct 2010 – April 2011

Business Analyst

HIPAA 5010 is a US Federal Government mandate which needs to be implemented by US Health

Insurance Industry and HIPAA complying entities by Jan 1st 2012. This implementation is replacing

incumbent version of HIPAA 4010 and replacement would be overhauling almost all of the Payers IT

systems. Implementation will consist of development of the new web services and complete remediation

of impacted IT systems of the Payer Industry, most critical of these being Claims processing and related

applications

Responsibilities:

? Use case document Creation, Process and Data flow Diagrams creation and other functional design

documents creation

? Responsible for creation of work breakdown structure from functional perspective for 270/271,

276/277, 837 P, I and D EDI transactions

? Developing expertise in understanding Transactions code sets for all the 9 EDI X12 Healthcare

Transactions and drawing test scenarios and test cases for the respective transactions sets

? Preparing Ambiguity Matrix based on the BRDs to get the clarified requirements from the Customer

SMEs

? SPOC for all the functional queries of Development team at offshore and getting them resolved with

Customer SMEs from the respective areas

? All types of BizTalk 2009 HIPAA 5010 Schema mapping and Common Claim format (Canonical

format) mapping review. Expert in XML – EDI Mapping, EDI, XML- Facets XC format mapping etc

? Designed and imparted a comprehensive training sessions of 28 hours covering Customer’s LOBs,

Business process flows and EDI transaction structures from TR3s detailing segments, loops and

element and the logical relationship among them

? Performing comprehensive BA activities for making Proprietary Provider Portal of the Client as 5010

Compliant

? Requirement Documents Creation, Requirement Traceability Metrics, Test scenarios and test cases

review

Environment: BizTalk, Asp .net, C# and MS Visio

Disease and Care Management Practice Nov 2009 – Oct 2010

Business Analyst

CT

As the SPOC for disease and Care Management practice team, responsible for product development,

gap analysis and preparing marketing collateral for the products spread across disease and care

management continuum

Responsibilities:

Hareesh Lingam

Sr. Business Analyst

? Single point of contact for the disease and care management practice product development and

marketing activities

? Competition analysis and target customer profiling

? Understanding the Requirements translating into solution needs

? Responsible for end-to-end RFX activities and Proposal Development

? Developing the product collaterals like presentations, videos, brochure, White papers, flyers

? Designing and updating the website content for the company website specific to the service offering

Just In Time Wellness: Just InTime Wellness is a member engagement and notification solution helps in

effective usage of healthcare services and involves members proactively engage in their health

Responsibilities:

? Developed the business case based on the market gap analysis

? Gathering the requirements

? Prepared use cases and activity diagrams

? Requirement and functional specification documentation

? Assisting the programmers to understand the various business processes

? Preparation of Functional test cases

? Developed marketing collaterals

Environment: Java, SQL Server, Oracle, MS SharePoint Portal HP Quality Center BPMN and MS Visio

PROFormance – Clinical and Financial Outcomes Reporting: The primary use of the “PROFORMANCE”

application is to evaluate the impact of disease and care management programs by providing the clinical

and financial outcomes reporting. It can measure PMPM (Per Member per Month) cost and utilization

rates and patterns by service type and population segment

Responsibilities:

? Requirement Analysis and developed the Business Requirement document

? High Level design documentation and developed the process flow for understating the Business “AS

– IS” and “TO – BE” understanding and Identifying constraints, boundary, assumptions, risks

? Generated the Functional Specification Document

? Involved in the preparation of Project plan, user acceptance testing

? Defining Rules using the ICD and CPTS for identification of Chronic Population

? Writing the rules and documenting the specifications as per requirements of client

? Business Test scenarios documentation and perform Validation of Processing logics at Micro and

Macro level

Environment: Java, SQL Server, Oracle, HP Quality Center BPMN and MS Visio

EDI Production Support for X12 837 Version 4010A1

BCBS Louisiana Sep 2007 – Sep 2009

Business Analyst

The project is about the Claim Adjudication Process for BCBS LA where benefits and pricing are applied

to the Claims after getting it validated for mandated HIPAA X12 transactions. Validated X12 Transactions

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files are sent to Legacy/Facets systems which then takes care of the entire Claim Adjudication process

and generates explanation of Benefits

Responsibilities:

? Responsible for imparting domain knowledge on HIPAA X12 transactions and how it is used as HIPAA

837 transactions

? Supporting project team in validating 837 Transactions by providing them with better understanding of

the business terms used in X12 transactions

? Clarifying business terms mentioned in HIPAA implementation guide to help project team map the

same with the technical fields in the middle ware schema

? Responsible for verifying mapping documents

? Making the team understand the Loop structure and how various information come under respective

Loops

? Instrumental in developing POC for transaction format conversion from HIPAA 4010 to 5010 for X12

837 P to commence with

? Coordinated with Technical Architecture team and imparted EDI X12 structure knowledge at all the

stages of HIPAA 4010 to 5010 POC development

Environment: Facets, Crystal reports, Asp .net

Health Insurance Competency

Mahindra Satyam May 2005 – Oct 2009

Presales Consultant / Business Analyst (Mahindra Satyam)

Health Insurance Competency provides domain inputs to the project associates in understanding various

business processes flows and imparts training to the technical and Domain resources in each of Satyam’s

accounts. Payer Competency is responsible for creating and promoting the Health Insurance specific

Service offerings and designing solutions targeting current industry trends and challenges. Competency

also provides consultancy services for its various projects spanning across all its service offerings

Responsibilities:

? Responsible for creation and enhancement of Insurance domain Service Offering binders

? Dissemination of Service Offering across the relationship units.

? Instrumental in creation of POCs as competency demonstrator for Customers.

? Responsible for conceptualizing the application with regard to POC, gathering requirements for the

same and coordinating with development and functional testing team.

? Created “Straight through Processing” POC pertaining to New Business.

? Creating work products on Health Insurance service offerings based on BASE TM that is Satyam’s

proprietary Business Analysis Framework

? Providing response to RFP’s and RFI’s.

? Creating high impact presentations on subject matter for Business development teams

? Authoring approach note for current industry trends like ICD 10 and HIPPA 5010, Health Benefit

Exchanges, Health reforms etc

? Preparation of Study Material for MSHIP training (Mahindra Satyam Health Insurance Practice) and

Instrumental in developing Training content for advanced MSHIP 102

? Collateral Authoring like Case studies, Thought papers, White Papers

? Responsible for Knowledge Management activities and enhancing domain knowledge capability of

the practice

ACADEMICS

? Master of Business Administration from ICFAI Business School

? Bachelors of Technology in Engineering from Jawaharlal Nehru Technological University

Hareesh Lingam

Sr. Business Analyst

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856 - 419 - 0238

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