Dhara Pandya C: 818-***-****

ad22nu@r.postjobfree.com

PROFESSIONAL SUMMARY

·MBA with 18+ years of experience in IT industry playing the role of lead System analyst in leading edge technologies.

·Proven ability to work effectively with all levels in cross-functional and cross-cultural work environments.

·Team player and a self-starter with requirement analysis and interpersonal skills, proven ability to work under pressure, prioritize and meet deadlines. Open to dynamic work environment and to learn new developments with ability to grasp and implement the same.

·Worked in various health insurance companies and have implemented multiple projects in Pharmacy savings, membership enrollment, pricing, underwriting.

·Certified Scrum master, Safe Practitioner 4.5 Certified and expertise in Agile methodology.

·Strong Analytical and Technical skillset including

oUsing Athena, Dbeaver and EMR to run SQL query for data analysis and validation for eligibility, medical claim and pharmacy savings data. Created complex mapping from source to target system, providing all technical joins, functions and detail business rules.

oAnalyze and track core business requirement and translate into functional requirements.

oReview and approve detailed business, technical requirements, design documents. Strong experience in defining and writing data mapping rules. Strong data analytical skills.

oWorking knowledge of Mainframe, SQL and DB2/QMF. Running SQL ‘select’ query using DB2/QMF tool, analyzing data, and writing mapping rules.

oExtensively worked in web-based intranet application, create mockups, and gather requirements for OLTP transactions.

oProvide business scenarios to create the test scripts and test plans from use cases. Led offshore team and translate business knowledge to the team.

EDUCATIONAL CREDENTIALS

·Master of Business Administration - MBA (Management of Information Technology)

Schiller International University, London, United Kingdom

·Master of Commerce – MCOM (Accounting and Auditing)

Gujarat University, Ahmedabad, India

·SAFE for teams 4.5 practitioner Certificate

·Certified Scrum Master from Scrum Alliance

PROFESSIONAL EXPERIENCE

Client: Ingenio-Rx/Anthem/Elevance Health/CarelonRx Woodland Hills, CA

Business Systems Analyst (contractor) Mar 2021 – Till date

Working on Ingenio-Rx/Carelon Clovr (Clinical Value Outcomes Reporting) system to calculate the savings for Medical and Pharmacy claims data. To Calculate savings for OPIOD medication using complex formulas. Analyze the source and target data to perform the validation.

·Worked on Agile methodology for Saving calculation where Ingenio-Rx can save from alternate medication and alternate location for client. SCME Project has PDC (Percent days Covered score number) calculation using Medical and pharmacy claims, CAG (carrier id, account id and Group id ) and member level information to slice the data at different level to show the numbers to client.

·Created complex mapping document from source to target data. Analyze the data, running SQL query using Athena, Dbeaver and EMR Tool.

·Created the test cases to validate data in CLOVR system to make sure source Data – IDL (IngenioRx Data Lake) has same data. Write queries including table inner/left joins, date functions, length comparison for field, and where clause with multiple tables.

·Review Mapping and test cases with team, record the session and load information to the confluence page.

·Attended daily stand up, sprint grooming, spring planning, retrospective, PI (Program Increment), requirement, design and test data review sessions.

Environment: Windows 2000 platforms, Microsoft Office 2013, AWS – Athena(Amazon Web Services, EMR (Amazon Elastic MapReduce) Tool, Dbeaver Query Tool, JIRA, Confluence, outlook 2013, Microsoft teams.

Employer: Anthem Woodland Hills, CA

Systems Analyst Advisor May 2010 – July 2020

Worked on ID card enhancement process, CDHP IND plan enrollment, CA subsidy enrollment for on exchange plan, discontinuation of Legacy plan, Individual and SG exchange Plan till date. Worked on Exchange reconciliation process till date, ICD9 to ICD10 project mapping, Indiana Medicare business, Large group, Small Group, and Individual letter common format mapping.

·Worked on agile methodology for letter enhancement project where letter needs to have common format for Large group, Small Group, and Individual business. Created mapping document for each business/per system (WGS, ISG, PSD). Worked with different systems POC to finalized design/mapping/requirements. Worked on letter field name for flat file covert to XML tag name for ISG/WGS/PSD system. Review and validate flat and XML file.

·Worked on Agile methodology to finalize Sprints backlog for each PI. Attend daily stand up calls with team and try to resolve other system impediments. Collaborated with Scrum master and schedule follow up call with teams and provide working solution for team members to expedite process. Attend and schedule all scrum ceremonies and complete each task.

·Use mainframe technology to view member data, table, and file. Wrote SQL ‘Select’ query to view member data. Worked on broker project to get real time data from broker system and updated batch process for the membership system.

·Schedule meeting with business to get business requirements, clarifications, and detail information regarding Individual CDHP plan enrollment for 2020. Provide clarification to developer, tester and other team members regarding requirements and design. Work closely with Technical lead, architect to finalized design as per requirements.

·Worked on ID card enhancement project where needs to eliminate ID card generation per state/per business/per product. Id card should generate as per business requirements and should stop generating ID card when it is not required.

·Worked on Individual and Small Group enrollment and eligibility reconciliation project since 2012 till to date. Created reconciliation process per state/per business. Worked with Exchange, business, ISG & WEM/E3 team members to finalized mapping and file layout.

·Worked on 834 enrollment file WCF (WellPoint common format) to add mapping rules for Individual business. Working knowledge on review WCF (834 enrollment file).

·Worked on Individual and Small group enrollment plan for on/Off exchange plan, created new exchange related tables and data in ISG system to identify exchange plans.

·Review business requirements, technical requirements, Functional Design document (FDD) and Technical Design Document (TDD), test scenarios and test cases. Worked closely with BA, Developer, business SME’s and tester to finalize all documents.

Environment: Windows 2000 platforms, Microsoft Office 2013, Mainframe, MS Visio, JIRA, Confluence, outlook 2013, Microsoft teams, WebEx, and Lync Skype for meeting.

Client: WellPoint/Anthem Woodland Hills, CA

Consultant - Business System Analyst Oct 2009 – May 2010

Project Description: WellPoint is the nation's leading health benefits company serving the needs of more than 33 million medical members nationwide in 14 states. WellPoint’s WCC Enablement Project is an implementation of WCC consisting of migrating data from seventeen membership source systems.

Responsibilities:

·Worked with business SMEs and developer for creating Common Format File Spec, define the business rules, required key field, history data elements, relationship between data elements.

·Performed the gap analysis CF doc, Cobol CF doc, and ETL CF doc, documents the recommendations.

·Worked with SME’s, BSA’s, ETL team to create ACES source to target mapping document, documented mapping rule, transformation rule, default rule.

·Worked with ETL team to understand the basic require data elements to process the group and membership data. Analyze the data elements from three source system (CS90, STAR & WGS)

·Worked with business SME’s, BSA’s, Data Architecture, Data Stewards and Data Governor’s for the ACES required fields and created new business terms, definition, and data model for WCC system.

·Performed Gap analysis between WGS s2t doc, CF doc and Data Dictionary document and make updates accordingly.

·Follow up with Payer, standard and Dental contract with Encoder Pro vendor and wellpoint manager. Worked with Ingenix vendor to get Encoder Pro tool for anthem associate. Schedule DEMO session and create user list and make sure everyone gets the access.

Regence Blue Cross Blue Shield Portland, OR

Consultant – Business Systems Analyst March 2009 – Oct 2009

Project Description: The BCBS Healthcare provides health benefits and health services for the corporate clients and Individual. I worked under RITS (Regence IT) System Analyst department. During my tenure I was working on Individual business conversion project from Legacy to Facets application.

Responsibilities:

·Review & document As-Is & To-Be Business Processes. Review and approve business use cases for the individual business conversion project. Facilitate JAD session with Clients – BOA, State of Oregon and external vendors - TriZetto and IBM to finalize the requirements. Work closely with Cash management, Finance and Membership Regence SME’s to capture premium due and member eligibility requirements.

·Create PDM (Physical Data mapping) & LDR (Logical Data Requirement) for data extracts for file and report. Create new tables and fields in the Facets applications and provide business rules, mapping rules for the source and target tables. Analyze data into the MS Access, ODS (Operational Data Storage) database and EDW (Enterprise Data warehouse).

·Documented requirements using NACHA format (the National Automated Clearing House Association) to send file to the external Client. Work closely with external client, internal SME’s, developer, solution engineer and tester to finalize the requirements.

·Documented meeting minutes, requirements specifications (Base BIR and Design BIR), process flow diagrams and stored artifacts on the Livelink. Documented guidelines to access set up for SQL navigator, Sybase and other internal applications. Provide training and guidance to newly join. Act as liaison between business, developer and tester.

·Facilitate JAD session between the different teams to identify the requirements gap. Re-distribute the work effort between teams and project. Review the other project requirements and identify dependencies, duplicate work effort and real requirements.

Environment: Windows 2000 platforms, Microsoft Office, Sybase, SQL Navigator, Business Object, MS Visio, MS Project.

Client: Kaiser Permanente Walnut Creek, CA

Consultant – System Analyst June 2008 – January 2009

Project Description: The Kaiser Permanente Healthcare provides health benefits and health services for the corporate clients. I worked under Business Solution and Innovation department. Work closely with Occupational Health group and Health Connect group. During my tenure I am involved in OH (Occupational Health) project. Involve in requirement gathering, designing and testing.

Responsibilities:

·Involved in all the phases of Software Development Life Cycle of the OH project. Tracking business requirement using MS Excel and CaliberRM. Involved in gathering, analyzing and verifying requirement with internal and external users. Facilitated JAD session with Chief Physician, Admin Staff, external customers, developer, tester and end users. Worked individually as well as a team member, identify & document As-Is & To-Be Business Processes.

·Followed UML methodology to create diagrams. Gather requirements for OLTP transaction, Single-Sign-On, refreshing page and security. Create process flow and activity diagrams using Visio. Create prototype, mockups, graph, and pivot table using MS Word, MS Excel and Visual Basic. Create ad-hoc report using Cognos tool.

·Analyze data from KP Health Connect (EPIC System) and Bedrock database. KPHC have normalized database, wrote mapping rules for NCal & SCal KPHC database. Wrote processing rule for migration and back up data. Acted as liaison between business, developer and tester team and finalize the requirement.

Environment: Windows 2000 platforms, Microsoft Office, Office Visio, Oracle, Microsoft Project, Caliber RM.

Client: Cigna Healthcare Bloomfield, CT

Consultant – System Analyst Nov 2005 – Oct 2007

Project Description: The Cigna Healthcare provides health benefits for corporate clients. I worked with Pricing and underwriting department. Work closely with Actuarial and Underwriters. During my tenure I am involved in four different projects.

1.CCF - Cigna Choice Fund – (Main Frame application). CCF packages a consumer health care fund with an underlying PPO or Open Access plus medical plan that has deductible, coinsurance and out of pocket maximum. CCF includes HRA (Health Reimbursement Arrangement) and HSA (Health Savings Account). Implemented CCF products, benefits, claims and membership data in pricing database (Mainframe application).

2.Paid Claim (Main Frame application) - change methodology from Incurred to Paid Claim. It also involved reconciliation of data between iTell Report Application and Pricing Database. Analyze discrepancies between claim dollars between two applications.

3.iQuote Application – Phase I (Web based intranet application) - creating new rate application for Guaranteed Cost product. Application will have product, benefits, claim experience, membership, rates and situs data from the new client. Analyze Renewal rate application – GCPM and wrote reverse engineering document. Both application (GCPM & iQuote) used by underwriting department, so kept similar functionalities where it’s possible. Based upon information application provides rates to the client. Phase I was applicable to client who has less than 200 subscribers.

4.iQuote Application – Phase II (Web based intranet application) – worked on iQuote project (Phase II) which supports ER, ASO and Minimum Premium Product. Phase II was applicable to client who has +200 subscribers.

Responsibilities:

·Involved in all the phases of Software Development Life Cycle of the project. Involved in gathering, analyzing and verifying requirement with business and SME’s. Facilitated JAD session with SME’s, Project Manager, developer, tester and end users.

·Compare data for various products and benefits in paid claim project. Products are Power Manage Health Care (PMHS), PPO, OAP and Consumer Driven Health Plan (CDHP). Gather requirements for OLTP transaction, Single-Sign-On, refreshing page and security. Create mockups, process flow and activity diagrams.

·Created ADS (Application Design Specification), BRS, SRS, Activity diagram, prototype. Wrote mapping rules for new data. Create Data Dictionary for project and update existing data dictionary.

·Analyze data from IM (Information Management Data warehouse) and HCE database. IM have normalized database, wrote mapping rules for pricing database – de-normalized data mart. Pricing Database stored historical data, so applied logical delete concept for data.

·Involved with data modeling session, explained mapping rules, data elements to the developers and DBA. Involved in creation of logical database. Involved in discussion for primary key, foreign key and naming convention for the table. Created 9 new tables for CCF project. Gather requirements for data storage for the tables. Performed Data Analysis using different SQL queries on Mainframe – DB2 TSO/QMF.

·Acted as liaison between business, developer and tester team and finalize the requirement. Acquainted new SA’s & SME’s of iQuote Phase II with iQuote Phase I functionalities. Documented business requirement for Security level of iQuote application, defined how many application users and who can have access to the application. Involved in Logical Database creation and create data dictionary template for the project.

·Led offshore testing team of four consultants and wrote Test script template. Work closely with underwriting team and create business scenario for Acceptance Testing. Work closely with testing offshore team and rectify their written test scripts, resolve the issues with their queries. Use Mercury Win Runner to implement Test script.

Environment: Mainframe Environment – DB2 TSO/QMF, Windows 2000 platforms, Mercury Win Runner, Microsoft Office, Office Visio, Microsoft Project.

Client: Cigna Group of Insurance Bethlehem, PA

Consultant – Business System Analyst July 2005 – Sept 2005

Project Description: The Cigna Group Insurance provides Disability, Life, and Accident Products for a broad range of clients. A project was for the Synchronization of two applications (UTS & VPS) and introduces online facilities for clients.

Responsibilities:

·Provided input to the project work plan for Business Analysis team activities and deliverables. Defined Business rules for the Underwriting System and worked closely with Underwriting Teams. Defined requirements through the Use Cases and detailed Supplementary Specifications

·Facilitated JAD session with SME’s. Involved in designing the system with the system architecture and the development team by translating the business requirements into a functional specification document.

·Documented critical business processes and internal controls. Wrote narratives, prepared templates, and created flow charts. Analyzed and developed Business Process improvements with the primary objective of reducing costs and increasing efficiencies.

Environment: Windows 2000 platforms, SQL Plus, Office Visio, Microsoft Project.

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