Hemina Patel

203-***-****

acuw0f@r.postjobfree.com

SUMMARY

* ***** ** ******** ********/ Quality Analysis experience with in-depth knowledge of business processes in health care and financial industries.

Expert in analyzing, identifying, tracking, evaluating, and recommending systemic changes to enhance productivity and efficiency as well as the methods and procedures for system maintenance.

Expert in Requirement Gathering, analyzing, detailing and tracking.

Experienced in documenting requirement using Unified Modeling Language

Excellent communication skills, Interpersonal skills, interacting with team members, leadership qualities, mentoring, ability to work independently.

Strong understanding of various SDLC methodologies such as Waterfall and Agile and have experience in all of them.

Extensive experience in IBM Rational Team Unifying Platform containing tools such as IBM Rational Unified Process (RUP), RequisitePro, ClearCase, ClearQuest, Share Point.

Good knowledge in healthcare insurance domain including Medicare. Proven experience with HIPPA X12 EDI transaction codes such as 270/271(inquire/response health care benefits), 834(Benefit enrollment) 835(Payment/remittance advice), 837(Health care claim).

Experience and strong understanding of ICD9-ICD10 Conversion Process with BTS Team of Rates & Benefits Department, Claims Processing, and other standards.

Experience in writing requirements and specification like Business Requirements Document (BRD), USE Case Realization Document, Functional Requirements Specifications, Requirements Traceability Matrix (RTM), Process mapping.

Expertise in performing GAP Analysis and Impact Analysis in several projects.

Quick learner, self-starter, can learn and adapt to new atmospheres and technologies with confidence and ease.

KEY TECHNOLOGIES & TOOL EXPERIENCE

UML Tools

Rational Rose / Microsoft Visio / Enterprise Architect 4.0/Provision

Rational Tools

Clear Case/ Clear Quest, Requisite Pro, SharePoint

Databases

Mainframe, Oracle, DB2, MS Access, SQL Server,

Methodology

Waterfall, RUP, SDLC, UML, Agile, JAD

Web Design

HTML, DHTML, XML

Front end tools

Microsoft Project, MS Visio

MS Office Tools

MS Outlook, MS Word, Ms Excel, MS Access, MS PowerPoint

Operating Systems

Windows 98/2000/XP/Vista/7, Mac OSX

PROFESSIONAL EXPERIENCE

AIG (directDME),

Farmington, CT June, 2015 – Current

Position: Quality Analyst

AIG traces its roots to 1919, when American Cornelius Vander Starr established a general insurance agency. An enterprising spirit, ingenuity, and tenacity have built the company into one of the world’s leading insurers. Today, AIG is focused on what it has been known for since the beginning: the willingness and ability to provide insurance coverage to meet the diverse needs of its clients.

I am involved in working on several projects listed below:

Operations Department:

Responsible in updating process documents such as Doctor Add, Product Add & Verifying FL-TX Doctor Licensure Information for operations team.

Used Vlookup to create a file for our vendor from data fetch from out database by a teammate in different files.

Understanding the current process of one vendor and getting involved in another project for changing few services from one vendor to another vendor.

Validating files from different vendors to make sure we have updated data/ information for people who work for operations department in few different locations to put in out contact list.

Responsible in providing more information to our vendor from Fastrack system & Injury Viewer which need for billing purpose on regular basis.

Expert in creating process document for change in phone call options for our main phone line and involved in giving training to our Customer Service Representative’s so that they can guide our patients correctly when they receive a call to make sure our operations run smoothly.

Responsible in creating the document for all our vendors and involved in giving training for phone switches from one vendor to another so that they can guide to our patients.

Responsible in adding the product in Fastrack requested by Customer Service Representative so that they can place the order for DME items for our patients and bill correctly.

Involved in looking orders more then 10K dollar amount.

Involved in ensuring the price we have in our system is correct based on ‘Fee Viewer’ as price varies from state to state and HCPCs codes.

Involved in verifying the doctor which is show in our patient claim for billing purpose, I was responsible to verify doctor’s license for TX & FL to make sure that doctor is clear/active.

Involved in adding new doctors in our system for our patients for billing purpose.

Involved in calling to our call center by which clients gets service from our vendor to make sure they talk to caller in same manner training was given to them, tested that to create a document for our new vendor service. To confirm if we need any changes when we change our new vendor to provide quality service to our clients/patients.

Involved in creating the process document and providing training to offshore team on WebEx to ensure they understand invoice import processing steps correctly.

Involved in checking the system for all the products which are no longer available and will not be available by vendor anymore by Obsolete that product from our system to avoid orders for those products from our patients.

Responsible in formatting the day to day reports and sending it to the team for our day to day operations.

Involved in testing for OCCM SFTP project for invoice batch processing and giving them signoff approval for QA testing.

Responsible in generating daily, bi-weekly, monthly & quarterly reports using crystal reporting tool.

ICD9-ICD10 Mapping:

Experienced and strong understanding for ICD9-ICD10 Implementation in Fastrack system.

Involved in working closely with Director to create the planning process for the ICD9-ICD10 implementation to run smoothly.

Expert in creating test cases from BRD or Change Request Document for email testing for our new vendor.

Involved in ICD9-ICD10 crosswalk mapping manually for operations department.

Responsible in creating test cases for ICD9-ICD10 project by creating negative and positive scenarios.

Expert in creating EDI test cases for ICD9-ICD10 changes in system by creating negative and positive test scenarios.

TheBigWord Project for telephonic interpretation and document translation services:

Involved in creating Roster for OPI database file from several other files with information like Role, First Name, Last Name, Email ID, Company work for, Company Office, Phone #, Extension. Phone Type, etc.

Involved in end to end testing for transferring telephonic interpretation & written document translation services from one vendor to another.

Responsible in creating test cases from QA & UAT perspective for telephonic interpretation & written document translation services by creating positive and negative test scenarios.

Expert in doing end to end testing for phone line switches for telephonic interpretation & written document translation services from one vendor to another.

Responsible to report a bug or error while testing the phone lines for our new vendor.

Involved in creating pricing sheets for new vendor services as billed rate sheet and quote rate sheet for operations team to check the invoice amount when we get invoice from our vendor and also to ensure the rate we invoice to our clients.

Responsible in doing negative and positive email testing for our new vendor by sending email in the new mailboxes for document translation services with different scenarios to see if it reaches to our new vendor on time.

Responsible in tracking the access for my team and report if any issues occur to director for our new application changes.

Expert in creating process change document for all our travel invoices for offshore team who manually process the invoices by overriding the price, this was a new process for offshore team and I was responsible to give them training.

Responsible in QA’ing the work done by offshore team by overriding the price and processing the invoice manually and to ensure that all the invoices processed by offshore team manually are correctly done to give best service to our clients.

Expert in validating date from production system to test region for testing purpose.

Involved in creating product id’s by setting up correct prices in our test region same as production so that the testing process smoothly.

Responsible in going through the detail call list from our new vendor twice in a week to make sure the detail call list is correct and non of the calls are duplicate calls before we bill to our clients for the service.

Involved in reviewing the invoices for our new vendor on daily basis to ensure all the information like Patient Name, Adjuster Name, Product ID, Patient ID, Claim # is correct before we receive purchase order for billing purpose.

Responsible in receiving PO after making sure all the invoices received from new vendor is fine with all correct information.

EmblemHealth,

New York, NY October 2012 – May-2015

Position: Business Analysts/Quality Analysts

EmblemHealth is a health maintenance organization and health insurance company based in New York City. It was formed in 2006 by the merger of Group Health Incorporated (GHI) and HIP Health Plan of New York to become one for-profit company. EmblemHealth is a big healthcare player in tri-state area with a range of products offering greater flexibility in benefit and pricing options to best match its member’s individual needs and health care priorities.

Rates Validation for ICD-9 & ICD-10 Conversion

Validated Global, Professional & Technical Rates for RBRVS File for Radiology & Surgical Lab

Analyzes, identifies tracks, evaluates, and recommends systemic changes to enhance productivity and efficiency as well as the methods and procedures for system maintenance.

Develops complete business specifications and screen designs for MCS and HCS system enhancements/modifications, recognizing any gaps and deficiencies and making recommendations to enhance current processes.

Oversees all system modifications that impact Rates and Benefits tables related to provider, facility, and member reimbursement.

Identify systemic issues based on daily reviews in both the HCS and MCS systems and develop process improvement plans.

Responsible for monitoring & adding rates in the Mainframe systems such as Corpprod & GHIpro.

Validate system modifications and perform user acceptance testing for I10 related changes, such as field expansion, code conversion, business rule configuration, and other related updates.

Perform postproduction validation to ensure accuracy of file releases.

Compiles, completes, and/or coordinates all documentation required by BTS, such as: special reports, Business Objects (BO) reports, spreadsheets, and other required forms.

Recommends system enhancements needed to be in compliance with contractual agreements.

Upload rates of EH Provides for previous years in mainframe systems.

Involved in Special Projects by Editing data in Mainframe and creating a report

Updated data in Mainframe for Fees schedule & Prevailing Rates.

Involved in meeting to identify the requirement related to BTS from BRD’s & Test Plans for

ICD-10 Testing

Involved in loading of rates packages in Prototype for MCS.

Involved in Creating Quest & RBRVS Test Plan for production in MCS system

Involved in Uploading Add On Codes for Special Handling Indicator, Winthrop Lab Rates in Mainframe for MCS

Validation for RBRVS rate file in Prototype Region

Loaded rates in MCS systems for the RBRVS Drug rates

Created test plan for MAPD Table & WPS table by taking screen shots from production region and test region of Medical & Hospital systems to ensure its copied correctly in test region for conversation of ICD9 to ICD10 conversation

Created MAPD ICD10 Diagnosis table for testing

Responsible for creating test plan overview by testing all the related screens on MAPD table & WPS table are copied correctly

Verified all the screens are accurately maintained its functionality and commands

Ensured all ICD fields continue to display from 5 bytes to 7 bytes and 125 fields from ICD9 to ICD10 conversion

Verified all ICD fields are left justified in MCS & HCS systems

Validated the data/codes to ensure accuracy of ICD9 to ICD10 codes, effective/termination dates and the new codes with the associated proprietary codes

Validated the ICD9 codes mapping to the ICD10 by taking screen prints of the mapping spread sheet according to the CPT codes

Revalidated open defects by updating in the Testing Verification Log

Reviewed Child rates are loaded correctly in systems by doing QA

Compared test plan screen shots with the respective extract grid to ensure all the new ICD10 codes are copied correctly in medical & hospital system

Loaded Quest Rates for few networks in medical system

Also involved in helping other team mates for creating HCS ICD10 Diagnosis Codes File by validating Mapped codes, Unmapped codes & the original set of codes from Extract file

Loaded RBRVS drug codes to ASP file in MCS system

Ensured by checking New 2014 CPT Codes for tabs labeled in file as CAT III and CAT II are loaded correctly in Medical system

Terminated the list of HCPCS codes in MCS system which are not in used in ICD10

Responsible for completing a post validation test plan for the assigned test plans by taking a screen print from MCS system

Terminated list of codes in MCS system on Crosswalk file

Reviewed ICORE codes in the crosswalk file in system to see if RNE is still on file.

Responsible in creating Mass Adjustment Test Plan & Overpayment Test Plan from settled report to verify that claims paid correctly for various departmental audits.

Develops and reviews post implementation reports for all assigned PPM’s and corporate projects. Reports discrepancies for resolution.

Involved in doing Post Validation for test plans created by other team mates to ensure that its calculated & paid correctly

Responsible in ensuring % rates for providers are correctly loaded in MCS in compare to provider contracts by creating PIV Test Plans to ensure that claims paid correctly

Loaded rates in MCS systems based on CPT codes & GHI codes for particular Svc codes

Involved in adding Benefit contract for Benefit Configuration department

Responsible for adding In-Network OP Mental Health cost-sharing to all the partial hospitalization target svc’s

Responsible in Updating CARC’S & RARC’S Denial Codes & Check Message Codes Update in Mainframe

Benefit Coordinator:

Responsible in loading new Contract for Benefit Team in contract file of Mainframe system

Involved in updating Benefit change on existing account for Benefit Team as per the requirement from Membership/Sales Team

Responsible for Post Implementation with Corrections/Update on existing accounts for Benefit Team

Verified new and Existing accounts loaded by teammates & ensuring that its loaded correctly in system

Involved in Terminating accounts which are no longer an EH member as per the instruction sheet provided by Membership/Sales Team

Maintaining Diagnosis & Procedure files in MCS & HCS system for Benefit Team

Involved in updating Emblem Health CR/ER Benefit Grids for Benefit Team

Developed & Maintained departmental PPM/Project Request for the team

Responsible for all Email Inquiries for the team

Involved in scanning instruction sheet provided by Membership/Sales department for our record and was also responsible in doing Post Implementation for contracts

Responsible in working on Departmental Projects related to ICD9-ICD10 codes & CPT/Diagnosis Code Validation

Environment: Window2003/2010, Mainframe, SharePoint, QCare, MS Office Suite, Mercury Quality Center 10.0, SQL Server 2000, MS-Project 2000/2007.

EmblemHealth,

Manhattan, NY July 2012 – October 2012

Position: UAT Tester

EmblemHealth is a health maintenance organization and health insurance company based in New York City. It was formed in 2006 by the merger of Group Health Incorporated (GHI) and HIP Health Plan of New York to become one for-profit company. EmblemHealth is a big healthcare player in tri-state area with a range of products offering greater flexibility in benefit and pricing options to best match its member’s individual needs and health care priorities.

EDI Gateway consolidation

Involved in EDI UAT Testing by creating test cases in Quality Center and executing for 270/271, 276/277, 837I, P and D, 835 transactions.

Reviewed GAP Analysis to enumerate major differences between 4010 and 5010 transactions format.

Interacted with BA’s, PM & Lead to discuss functional and Non-functional testing in regards to system

Worked towards resolving various defects and updating status reports for weekly business and technical meetings.

Leveraged Quality Center to log and co-ordinate defects.

Involved in creating test cases with positive & negative scenarios for all EDI transactions.

Created dummy claims by using Ultra Edit to check the response of the system.

Used BizTalk In & BizTalk Out for dropping all edited claims to check claim process & procedure to get desired output

Environment: Window2003, Mainframe, BAM, BizTalk In & BizTalk Out, Ultra Edit, SharePoint, MS Office Suite, Mercury Quality Center 10.0, MS-Project 2000/2003.

Gentiva Healthcare Services – Tampa, FL March 2009 – July 2012

Position: Business System Analyst

Gentiva® Health Services is the nation's leading provider of comprehensive home health services. Gentiva serves patients through more than 350 direct service delivery units within approximately 250 locations in 35 states, and through CareCentrix®, which manages home healthcare services for many major managed care organizations throughout the United States and delivers them in all 50 states. Gentiva Health Plan is a community-accountable health plan that serves nearly 800,000 residents through four free or low-cost health insurance programs: Medi-Cal, Healthy Families, Gentiva’s Healthy Kids.

Coordination of Benefits (COB) is a Health Care Financing Administration (HCFA) Program undertaken by Gentiva. Medicare Coordination of Benefits is the process for ensuring that payment of Medicare beneficiaries' claims is properly shared among insurers when the beneficiary is covered by private insurance in addition to Medicare. By coordinating benefits, the COBC assists Medicare in paying claims more accurately the first time, which saves costly follow up and mistaken payments.

Responsibilities:

Gathered requirements and prepared business requirement documents (BRD).

Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.

Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.

Created and maintained data mapping document(s) in reference to the claim process transactions.

Involved in processing the claims to ensure claims are being processed correctly

Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to define the Data Process Models.

Involved in /EDI transactions Analysis, Design, Implementation and Documentation.

Reviewed in preparing the Test Scenarios for Health Care Claim Payment/Advice.

Maintained Requirement Traceability Matrix (RTM).

Presented the nursing outcomes to C-Level executives in Gentiva Nursing and Data Management group using Crystal Reports XI.

Use Case development using modeling tool MS Visio.

Maintained documents for change request and implemented procedures for testing changes.

Environments: Rational ClearCase, SharePoint, MS Visio, MS Project 2000, HTML, SQL Server, MS Office (Word, Excel, PowerPoint).

Bank of America (Accenture) – Charlotte, NC May 2008 – Feb 2009

Position: Business/ Systems Analyst

Bank of America provides commercial, retail banking services as well as different credit cards to customers and businesses. The client wanted a more accessible and comprehensive application that has viewing ability, which would enable customer to easily access various features. As well as the application was supposed to be connected with the customer service to update data, payment information, transactions and so on. The front end used was JAVA, whereas the backend used was Oracle.

Responsibilities:

Stakeholder interviews, Requirements review, preliminary system design, and joint application design workshops, and Error and Corrective Policy and Procedure.

Developed project delivery schedule, managed projects and identified resources to successful completion

Set up HR vendor system, Benefits, Benefits Open enrollment, Compensation and Payroll.

Managed Project Management staff, Quality Assurance and Technical Writing staff.

Acquired comprehensive knowledge of Banking activities and operating processes

Collected and documented business processes as well as business rules.

Participated in the identification, understanding, and documentation of business requirements, including the applications capable of supporting those requirements.

Maintained data mapping from source to target files.

Translated the business needs into system requirements, communicating with the business on a non-technical level, and with the System Analyst on a more technical level.

Collaborated with development architect and the business to develop both high-level and detailed application architecture to meet the business needs.

Documented and delivered Functional Specification Document to the project team.

Performed GAP Analysis and conducted User Acceptance Testing (UAT).

Conducted project related presentations.

Environment: MS Visio, MS Excel, MS PowerPoint, UAT, Rational Requisite Pro, Rational ClearCase, SharePoint.

Washington Mutual (Accenture India) – Seattle, WA June 2007 – May 2008

Position: Business Analyst

Washington Mutual, based in Seattle, WA is a Fortune 500 banking and financial services provider, having a nationwide presence in over 50 states. Accenture is a trans-national management-consulting firm, with a domestic and global presence, servicing corporate in a plethora of domains and industry expertise.

Worked in Washington Mutual's Cash Management services division. This division has various services under its umbrella like Information Reporting, Deposits and Collections, Disbursements and Cash management services. Each division has its own applications and the team was responsible for the testing of these applications in the cash management services division.

The project primarily comprised of my participation as a Functional Analyst in the Accenture Enterprise Architecture-Utilities team for specific assignments of priority. iFast and iStream were the applications whose functional analysis, use case preparation and coordination were under my purview, handling chief responsibilities as follows:

Responsibilities:

Reviewed and analyzed Business requirements and interacted with the business users to resolve conflicts.

Constructed data lineage information on usability and conceptualized data applications in a program-level scenario, high-lighting the “happy” or base flow and probable exceptions.

Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures.

Constructed, developed and deployed ACH Money Transfer documentation for Overseas Business Unit, created functional and technical specifications (mid-level), highlighting chief actors, process flows and exception errors.

Responsible for working with various Overseas Funds Transfer Applications.

Interacted with Offshore development team, incorporating the analysis and requirements in the final detailed design documentation.

Reviewed and provided critical document feedback to team members, communicated document analyses to team lead and stake holders.

Data Mapping from source file to target file.

Used MS Project to develop project schedules and tasks.

Worked with QA team to design test plan and test cases for User Acceptance Testing (UAT).

Environment: Rational RequisitePro, RUP, UAT, MS-Project, MS Visio, Java, MS Office, Windows XP.

Education: Bachelor of Business Administration.

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