Data Analyst
Resume:
Dinesh Yedupati
*********@*****.***
Summary:
Over 6+ years of extensive experience as a Business/ Data Analyst with strong experience in Healthcare Claims and Benefit Enrollment Process and Maintenance.
In-depth knowledge and experience in full SDLC with RUP, agile and waterfall methodologies.
Experience in health Care Industry with vast knowledge on Medicare and Medicaid, Claims/Billing, EDI transactions
Medical Claims experience in Process Documentation, Analysis and Implementation X12 Standard processes.
Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions.
Experience with Facets 4.71, Inbound & Outbound interfaces, EDI configuration, and data mapping.
Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
Enhance data and business requirements, identify Gaps and mapping for DWH redesign and update detailed Functional, Technical, and Product specification documents.
Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
Extensive experience in claims adjudication with a solid understanding of Business Processes Flows, Business Analysis, Requirement Analysis and Business Modeling and Use Case development using UML methodology.
Responsible for routine and ad-hoc reporting from Data warehouse. Ensure data accuracy in collaboration with technical team and resolve data issues.
Expertise in creating prototypes and mock-ups for user interface designs.
Specialized in creating UML Diagrams like Use Case, Activity and data flow diagrams using Rational Rose and MS-Visio and consistently translate business requirement into IT solutions.
Expertise in RDBMS concepts and running SQL queries.
Worked on the integration of the applications using middleware such as ADO.Net, XML and Visual Basic.
Developed statistical models using SAS enterprise miner which boosted overall customer outreach.
Created Business and functional requirement documents for the conversion process.
Designed and developed scenarios based on business requirements.
Involved in Functional System Testing, Integration Testing, Regression Testing, and UAT
Involved in project status meetings, QA review meeting, and System Test meeting.
Experience analyzing environments with multiple data sources and capture necessary data requirement
Skill Set:
Methodologies
SDLC, RUP, UML, JAD, CMM, RAD, Waterfall, Agile (Scrum Approach)
Testing Tools
Rational Enterprise Suite, CMDB, Quick Test Pro, Win Runner, Load Runner, Test Director, ITIL, ETL, Restful, SAP.
Change Management Tools
Rational Clear Quest, Jira
Business Modeling Tools
Microsoft Visio, Bizagi, Rational Rose, Power Designer
Defect Tracking Tools:
Bugzilla, Rational Clear Quest
Databases
SQL Server, MS-Access, SAS
Project Management
Microsoft Project, Microsoft Office, Team Foundation Server (TFS)
Education:
Northwestern polytechnic university- 2013-2015(3.6Gpa)
Masters in CS
Vignan University- 2007-2011(73%)
Bachelors in mechanical Engineering
Professional Summary:
CCAH (Central California alliance for health), Santa Cruz, CA Jul 2016 – Till Date
Business System Analyst/ Data Analyst
The Alliance is a health plan that was developed to improve access to health care for lower income residents who often lacked a primary care “medical home” and so relied on emergency rooms for basic services. The Alliance has pursued this mission by linking members to primary care physicians and clinics that deliver timely services and preventive care, and arrange referrals to specialty care. I am working on the data migration and the EDI claims.
Responsibilities:
I was involved in gathering Business Requirement and working as liaison between varies I.T departments.
Reviewed the Business requirement, Functional Design Documents, Technical Specification documents, to develop Test Cases.
Worked on EDI transactions: 270, 271,835, and 837(P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
Extensively used SQL statements to query the Oracle Database for Data Validation and Data Integrity.
Medical Claims experience in Process Documentation, Analysis and Implementation in835/837/270/271/277(X12 Standards) processes of Medical Claims Industry from the Provider/Payer side.
Inventory Management - Monitors all aspects of the CA claims inventory to ensure proper turnaround for: claims entry/processing, provider correspondence/appeals, express request and ClaimsXten.
Created Traceability Matrix to ensure that all requirements are being addressed.
Analyzed the Data Gaps identified by SOA and DWH, met with users to determine if the Gap fields were used and provide greater clarity on fields that were require
Lead the UAT testing during the project.
Configured and maintained Facets and other application software products, such as Claim check, Facets.
Worked on FACETS Data tables and created audit reports using queries. Manually loaded data into FACETS and have good knowledge on FACETS business rules
Took part in developing test plan, test scripts, and developed UAT test cases associated with the functional requirements.
Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management system.
Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance.
Environment: Rational rose, SQL Plus, Claims XTEN QC/ALM, Rational Requisite Pro, MS Visio, MS Office Suite, MS SharePoint, Quality Center, Agile and Water fall, SAP, Windows, XML, Jira, Restful and HTML.
BCBS (Blue Cross Blue Shield), Jacksonville, FL Jan 2015 – May 2016
Business system Analyst/ Data Analyst
Blue Cross and Blue Shield Association, is the largest customer-owned health insurer in the United States and fourth largest overall, operating through our Blue Cross and Blue Shield plans. I am working in the Enterprise Product platform (EPP) team on multiple projects (Standalone dental, ACA machine Readable and SBC).The purpose of BARS (Benefit Accumulator and Remediation Support) has been to improve usability constraints from the members and providers accessing their associated portals.
Responsibilities:
Gathered Requirements and created process flows for Premium Payments (Billing) and Member Services.
Performed Gap Analysis for Marketplace in regards with the Medicaid system.
Participated and facilitated JAD sessions to enhance requirements and create use cases and test cases.
Worked alongside Enrollment team to structure the premium payments based on the federal and state guidelines.
Performed Federal regulation sweeps and identified impacted areas and interdependencies.
Designed and documented Business Requirements (BRD) by using ASCI X12 EDI guides, reviewed and interviewed business process owners and companion guides.
Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
Involved in Processing EDI 837 Healthcare Claims (Institutional and Professional) in PORTAL with valid TPI.
Involved in testing Facet Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.
Worked on Allscripts workflows, and user profiles using Allscripts version 11
Great knowledge of EDI (Electronic data interchange), 834 and 837.
Developed use cases and functional requirements derived from business input. Initiated importing requirements into Rational Doors Next Generation for tracking, traceability and reporting.
Cyber threat vulnerability assessments (multiple descriptive statistics against raw data) and proactive scanning methodologies to quantify external risks.
Implemented and Used SWIFT messaging system to test the flow of messages from and into the new system and was also involved in ETL process.
Knowledge on payment product workflows like SWIFT (payment messaging system)
Contributed in reviewing and editing of the test scripts.
Participated in project review meetings to resolve defect related issues. Developed key metrics to use in benchmarking and gauging team performance against prescribed service level agreements
Performed source to target(Data warehousing) data validations
Worked through Agile framework with Iterative process and sprint cycles.
Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
Completed banking migration project for HB EFT payers to send claim payments to new bank account.
Setup Homecare payers for electronic billing (CPR+, Office Ally) and HB payers for EFT/ERA
Identified various call types for member services based on the call volume for Medicaid system in place.(ID card request, Benefit clarification, PCP change, network adequacy and others).
Identified and created SOPs and training necessities for the CSRs.
Tested the HIPPA EDI 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data on different modules.
Working on Set up and maintained Rhapsody monitoring for new and existing clients.
Participate in personal training to ensure technical knowledge is kept current with a primary focus in Rhapsody.
Created Inbound and Outbound call scripts for Member Services.
Creating a Work breakdown document (WBD) to identify specific tasks for the call center operations of the Marketplace project along with the management team.
ICD 10: Responsible for conducting and analyzing the impact analysis of the conversion from ICD-9 to ICD-10.
Good knowledge of HCPCS/CPT coding formats and modifier
Environment: MS Visio, MS Office Suite, Team Foundation Server and SQL Server, Bizagi, ITIL, Restful, Jira, Wireframes, Workflow Diagrams, Remedy Change manage, Bugzilla SAS, SAP, SharePoint, ClaimsXten.
MEDICA, Minnesota, MN Oct 2013 – Dec 2014
Business Analyst/ Data Analyst
Managing and overseeing day-to-day operational activities associated with conducting clinical trials from Phase I-IV. Adopting Meaningful Use in implementation of the All scripts MyWay EHR system for higher reimbursements, incentive pay, greater patient satisfaction and reinforce better patient and provider data management in compliance with HIPAA for Medicaid and Medicare, managing the Shared Accumulators Application, and improve the overall group on boarding process.
Responsibilities
Administer Phase I-IV and investigator initiated clinical trials including study protocol development and revision, financial planning, IRB submission, ensuring NIH compliance.
Phase II Repeat Dosing Clinical Trial of Investigational Product in Subjects with Diabetic Neuropathy.
Ensure compliance to responsibilities as outlined in research protocols, institution policies, as well as federal regulations.
Analyze requirements for integrating Workers Compensation Information System.
Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
Worked on the Mapping Error of Facet Claims Engine System which in return impacted the Authorization and the Enrollment Module of the system in Agile Methodology.983
Provided Health Insurance domain and TriZetto's FACETS (version 4.51) training and mentoring to other internal
Worked with multiple teams to configure groups, products, BSDLS, and membership enrollment in Facets Production (PROD) and PPMO (test) environments.
Understood the Shared Accumulators Application and managed multiple work requests on a very aggressive timeline.
Novice to All scripts practice management.
Accountable for numerous steps in the estimating, communicating, design and coordinating the process, meetings, and delivery of Shared Accumulators work.
Invoicing the payers about the outstanding amount and proactive recognition and reimbursement of any excess payment
Ad-hoc and custom reporting to support Claims, Finance, Legal & Compliance departments.
Trizetto Facets for member demographic information, and other related information.
PRA - Premium reconciliation Application for reconciliation of payments
Coordination of Benefits (CoB) Application.
SSRS, IT, Facet generated reports.
Provide data maintenance for clinical trials.
Strategize configuration of Facet modules such as Claims, Membership, Billing, Benefits and Plan.
Ensure Meaningful Use and HIPAA compliance within the business processes and system configuration.
Experienced in creating mapping for loading Benefits in Facets. Analyzed a wide range of FACETS configuration change requests for the purposes of determining the technical scope of the change, its impact on existing systems configuration.
Hands on experience on Oracle Identity Manager and Identity and Access Management.
Performed analysis in Membership and billing data from Facets.
Work closely with clinical and revenue cycle architects, decision support application users to implement best practices and systems improvements.
Act as liaison between the SMEs from various LOBs and the technical team by supplementing documentation and conversion of business needs to technical specifications.
Manage and participate in acceptance testing to find errors and confirm program upgrades and hot fixes that meet all workflow specifications.
Develop and maintain accurate and detailed training curriculum, trainings databases, and training materials based on office workflows and current vision of applications within scheduled time frame.
Environment: XCode 5.1, Objective-C, Github for version control, XML, JSON, OLTP, OLAP, Wireframes, Workflow Diagrams, Remedy Change manage, SAP, SAS Facets, SharePoint, ClaimsXten
IMAGE Inc., Mumbai Jul 2011– Aug 2013
Business Analyst
Description: Worked on issues for the provider and member load issues and work around.
Responsibilities:
• Worked in Facet Batch Process such as Eligibility Batch Process, Mass Plan Change Batch Process, and ID card batch process.
• Coordinated and conducted system requirements walkthroughs/sessions (JRDs/JADs) with business Owner/stakeholders/SMEs as well as design/development teams.
• Worked with business area SMEs/analyst to develop and finalize test plans/scripts/use cases.
Familiar with Straight Through Processing (STP) utilizing electronic delivery of trade data to portfolio accounting, custodian data via SWIFT messaging.
• Worked on developing the business requirements and use cases for Facets Batch Processes, automating the billing entity. Research a wide range of moderately complex activities and claims issues in relation to the setup and administration of accumulators in our own system, as well as Facets and Cosmos
• Involved in impact analysis of Facet adjudication system as a result of change in EDI transactions.
• Involved in claim adjudication process of Facet application.
• Analysis of key business requirements and develop Business Requirement (BRS), Functional Requirement (FRS).
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan.
• Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed (837P, 835, 834).
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system).
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Conducted detailed and comprehensive Business Analysis by working with end users and other stake holders to identify the system, operational requirements, and proposed enhancements.
• Facilitated JAD sessions to identify business rules and requirements.
Environment: Rational Unified Process, MS Project, SAP BI, MS Visio, MS Word, MS Excel, SQL, PL/SQL, Windows NT/2000.
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