Jojan K

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732-***-****

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ad3vjk@r.postjobfree.com

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New Jersey

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PROFESSIONAL SUMMARY

* ***** ** ************ ********** in business analysis, business modeling, requirement gathering and writing Business and Functional Requirement documentation.

Through understanding of Software Development Life Cycle (SDLC), involved in all phases from planning to the implementation stage.

Good understanding with different development methods like Agile (SCRUM, KANBAN & SCRUMBAN), and Waterfall.

Experienced in documenting Business Requirement and Functional Requirements/Specifications.

Efficient in conducting JAD sessions, Feasibility studies, SWOT Analysis, Risk Analysis as well as Impact Analysis.

Comprehensive understanding of Health Insurance Claim Processing and claim repricing.

Familiarity with industry standards such as HIPAA 5010, ICD 9, and ICD 10.

Understanding of Medicare/Medicaid, Medical billing, benefits Health insurance Life cycle, EOP and EOB and Claims Processing.

Strong knowledge of EDI and the ability to communicate in EDI terminology with vendors and team members.

Experience in processing EDI Files 270/271, 276/277, 834, 835, 837(I), 837(P).

Good understanding and knowledge of HL7.

Familiarity with Value Based Health Care model and disease management programs.

Good understanding with different Payment Models like Capitation and Fee for Service.

Expertise in working with Project Managers in handling Change Request.

Used File Transfer Protocol (FTP) for exchanging files with vendors.

Successful as a team player to work as team with testers, developers, Scrum masters, Product Owners, and Project Managers.

Exceptional ability to quickly master new concepts, strong communication, organizational and interpersonal skills.

Strong leadership, mentoring, analytical and problem-solving skills.

SKILLS

Business Analysis

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Requirement Elicitation & Analysis

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Workflow Analysis

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System Integration

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Data/Process Flow Diagrams

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Stakeholder Management

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Project Management

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Change Management

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Process Development

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Process Mapping

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Business Rules

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User Acceptance Testing

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Software Development Lifecycle

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Waterfall

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Agile (Scrum and Kanban)

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Structured Query Language (SQL)

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Microsoft office

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Visio

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Jira and Confluence

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Trello and Asana

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EDUCATION

MBA IN HEALTH CARE MANAGEMENT

University of Northern Virginia, July 2012

MASTER'S IN SCIENCE OF PSYCHOLOGY

Punjabi University, May 2007

CERTIFICATIONS

Certified Scrum Product Owner (CSPO)

Certified Scrum Master (CSM)

Professional Scrum Master 1 (PSM1)

PROFESSIONAL EXPERIENCE

MultiPlan, New York

April 2023 - Present

MultiPlan uses technology-enabled provider network, negotiation, claim pricing and payment accuracy services as building blocks for medical payors to customize the healthcare cost management programs that work best for them. MultiPlan is committed to helping healthcare payors manage the cost of care, improve their competitiveness, and inspire positive change. Leveraging sophisticated technology, data analytics and a team rich with industry experience, MultiPlan interprets customers’ needs and customizes innovative solutions that combine its payment and revenue integrity, network-based and analytics-based services.

SENIOR BUSINESS ANALYST

Creating client facing BFRD and supporting documentation as per the Client's requirements.

Reviewing documentation with internal Stake holders and vendors.

Works with the team to understand End to End process to identify trends and gaps.

Reviewing the historical EDI files for creating EDI Specification for new processes.

Actively participating in Daily Scrum Stand up, Product refinement, Sprint review and Monthly Retrospective.

Writing stories on the JIRA Board and reviewing with team in Product Refinement sessions.

Actively working with Product Owner and Scrum Master to refine Product Backlog.

Engaging with Testers and Developers to track Bugs and Spikes on the JIRA Board.

Creating Process documentation on the Confluence.

Using VISIO for creating Swim lanes and Workflows in BFRD's.

Attended Scrum training and have actively participated in the transition from waterfall to Agile.

Organizes information and data to identify and explain major trends, problems, and causes.

Using Toad Oracle for running SQL queries.

Analyzing data and using it for Project description documentation.

Closely working with Project managers, Developers and Testers for completion of the project.

Actively involved in internal project meetings for understanding projects details, current processing, and modifications.

Engaging in multiple project meetings from kick-off to completion and maintenance.

Diligently working with Account management to document change request for vendors.

Working with developers to refine data mapping to transform the data according to business rules.

Prepared presentations summarizing findings from various analyses for team.

Authored detailed functional specifications documents outlining the requirements for development teams.

Identified gaps and areas of improvement in current processes.

Analyzed existing data sources to uncover trends and patterns for creating a baseline for Re-architecture.

Maintained a repository of business rules, user stories, acceptance criteria, use cases, flowcharts, and other documents related to current systems.

Provided support during user acceptance testing phase ensuring successful implementation of new applications.

Facilitated workshops with stakeholders to define scope and objectives of new initiatives.

Reviewed Technical Design Documentation with Development and Testing team to ensure accurate development of reporting solutions.

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Flume Health, New York

December 2022 - February 2023

Flume Health is a digital TPA helping self-insured employers make their health plans more affordable and easier to use. Flume Health is building the first modern health plan administration platform - with the mission to become the backbone of most health plans in the US. FH platforms unlock efficiencies in health plans that result in measurably better health outcomes for members and 15-40% lower costs for payers. FH is coming with the vision to impact the entire payer supply chain from the way a member finds their doctor, to the payments happening in the background.

EDI ANALYST

Created and updated guidelines and specifications for data exchange.

Connected with existing vendors to get the data specifications.

Provided KPI reporting on EDI File transaction processing.

Collaborated with trading partners to successfully maintain EDI processes.

Managed the resolution process and escalated EDI issues as needed.

Tested 834, 837 and 999 files in a staging environment.

Worked on Eldorado Javelina tools and systems in processing the 834 (Eligibility), 837 (I) and (P) Claims and 999 (Ack) EDI files.

Manually corrected EDI files for the processing of the claims.

Evaluated the current claim processing system, identified the gaps, and suggested improvements accordingly.

Assisted in developing new business partner relationships actively attended kick offs to understand the scope of the project.

Performed audits on existing systems for compliance purposes according to established regulations.

Monitored incoming messages from trading partners for accuracy before releasing them into production environment.

Updated documentation of EDI system configurations as per active processes.

Resolved complex electronic data interchange issues by collaborating with internal teams such as IT, Finance and Operations departments.

Tested end-to-end functionality prior to deployment into production environment.

Analyzed data from various sources to identify inefficiencies in existing processes and develop strategies for improvement.

Performed daily monitoring of all EDI transactions, ensuring timely completion of all transmissions within timeframe.

INDECS Corporation (Lyndhurst, New Jersey)

December 2020 - December 2022

INDECS is one of the leading third-party administrators in the Mid-Atlantic region, specialized in providing health benefits that fit everyone’s needs and goals. INDECS provides their clients with the finest Employee Benefit Claim Processing Center, offering superior customer service to every plan member, and the most effective and responsible Benefits Administration and information to Plan Management. INDECS works with a referenced based pricing company named; Claim Watcher and a Reinsurance company named as Homestead Insurance Company.

INDECS and Claim Watcher work together in bringing new TPA’s and implementation of TPA’s. Claim Watcher focuses on shifting the power back into the employer’s hand through pricing transparency and claims auditing technology.

SENIOR EDI ANALYST

Efficiently managed daily EDI operations for claim processing and reporting.

Actively engaged in manual correction and validation of claims.

Used crystal reports for creating different reports for claim examiners.

Closely worked with Managers and System Analyst in identifying the impediments in projects.

Facilitated meetings with new vendors and TPA’s to understand business requirements and functional requirements.

Documented client requirements and file specifications for the future implementations.

Worked with testers for end-to-end testing before implementation.

Actively engaged with System Analyst for identifying the automation opportunities and improvising the processes.

Performed detailed analysis on current systems and proposed solutions.

Used SQL queries and stored procedures during daily tasks to update data in the database.

Worked as a Liaison between IT technical department and TPA’s to ensure error free EDI transactions.

Documented detailed specifications of X12 data format standards for different EDI files.

Trained junior EDI Analysts and Business Analysts to work on daily file processing and handling errors.

Authored Companion Guide for 837 (I) and 837 (P) to define file processing requirements and HIPAA Standards.

Worked on WLT tools and systems in processing the 834 (Eligibility) and 837 (I) and (P) Claims files.

Created mapping documentation for 835 transactions.

Documented existing procedures for different vendors.

Managed different projects from design to completion.

Involved in SNIP Level Validation for EDI Files.

Used ASANA and Trello for managing and tracking the projects.

Created Process Flow Diagrams using MS Visio.

Created and maintained process documentation and provided training to external users.

Maintained a close and strong working relationship with teammates.

Conducted project related presentations periodically for the team and end users in various phases of Software Development Life Cycle (SDLC)

Facilitated communication between stakeholders and technical teams.

Collaborated with developers to ensure that product designs meet customer needs.

Provided support for Claim Entry Portal, reporting systems, and other tools.

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North America MedTech Group (Atlanta, Georgia)

February 2019 - October 2020

NAMG provides best in class reliable services related to healthcare systems that reduce the management costs and save time enabling doctors to focus more on patient’s health. The range of services include patient portals, hospital management portals, insurance claims, processing software that seamlessly integrates both hospital and insurance service providers, managing doctor’s database that includes his/her experience, specialty, user reviews and other important information.

EDI BUSINESS ANALYST

Prepared Business Requirement Documents & Functional Requirement Documents for different projects.

Worked extensively with developing business rules, enabling rules such as referral, prior authorization, eligibility, claims processing and billing.

Analyzed and transmitted the business requirements into detailed test plans and project plans.

Interacted with Subject Matter expert (SME) and carefully recorded the descriptions by asking detailed questions and documented them so that both business and technical teams can share common understanding.

Used Agile Software Methodology using Scrum framework.

Created user stories describing business requirements for Development team.

Involved in testing for claim processing system and claims life cycle.

Worked on EDI transactions: 270/271, 276/277, 835, 837(I) and 837(P).

Performed GAP Analysis for new functionality requirements and prioritized them based on the business needs.

Worked with Data Analysts to create Data Flow Diagram (DFD), Entity Relationship (ER) Diagrams and Use Case Diagrams.

Conducted peer reviews and walkthroughs with insurance SMEs (subject matter experts) and stakeholders in the company.

Actively involved in meetings and communication with new clients throughout the lifecycle of the project.

Assisting Project Manager in handling the change requests.

Monitoring project efficiency to complete on time.

Conducted JAD sessions, meetings, workshop to elicit requirements from various stakeholders and SME's.

Used Trello to manage project, created to-do list cards for the team.

Created Process Flow Diagram using MS Visio

Prepared comprehensive Use Case Specification & Mapping documents by identifying the use cases from the collected business gathering document.

Facilitated all aspects of Scrum Framework including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and spring retrospectives.

Created data mapping to transform the data according to business rules.

Created and maintained solution documentation and provided training to client users.

Worked closely with team to clarify and understand functionality and documented the scope of the project.

Delivered presentations on project progress at regular review meetings.

Researched industry trends to inform technology decisions.

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Highmark Blue cross Blue Shield (Pittsburg, Pennsylvania)

September 2017 - January 2019

Highmark BCBS is a large US based health benefits company and the largest member of blue cross blue shield association. It offers a spectrum of network-based managed care plans to the large and small employer, individual, Medicaid and Medicare (senior markets).

BUSINESS ANALYST

Worked in all phases of the project to review project deliverables for completeness, quality, and compliance.

Performed detailed research to identify impacts to existing systems and to come up with options to accomplish Business Needs.

Send notifications to various EDW-teams to notify changes that will be implemented that may have potential impacts to other existing processes.

Created a Process Definition Document.

Assisted team to remove impediments by having control and release processes.

Actively attended all the Scrum and Agile training.

Assisted scrum team in applying Agile principles in Software Development Life Cycle.

Attended various JAD sessions to discuss impacts and Statement of Work (SOW) items with the business team.

Created Detailed Requirement Document after meeting with End Users to define the Business and Functional Requirement.

Participated in all meetings conducted for defining Project Plan, Project scope and Project Schedules.

Maintained traceability of the test cases with the requirements.

Assisted QA team in detailed system testing and documented results for each test case.

Created Production Support Transition Document and Performed walkthroughs with the Production Support Team for any future ticket handling requests.

Provided all the support to the team in adopting scrum framework.

Provided technical support during user acceptance testing cycles.

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GE HealthCare (Milwaukee, Wisconsin)

January 2016-June 2017

GE Health Care provides medical technologies, digital infrastructure, data analytics and decision support tools that help healthcare professionals in diagnosing, treating, and monitoring their patients.

JUNIOR BUSINESS ANALYST

Conducted requirement gathering sessions for business processes and prepared documentation.

Worked with Development Team and Project managers for conducting knowledge sharing sessions and workshops.

Facilitated meetings and sessions with business and technical resources to understand business logic/rule and data flow configuration.

Tracked and documented the performance of the project from start to end.

Used SQL queries to pull out data from the databases to analyze the current trend.

Interacted with Account Managers and Development Team to finalize business requirements, functional requirements, and technical requirements.

Actively worked with Testers for creating Technical Specification Document.

Created Use Cases, Use case Diagram, Process Flow Diagrams, and workflow Diagrams.

Involved in Functional Testing, Regression Testing, User acceptance Testing (UAT), and Security Testing.

Conducted combined and individual review session with business and technical Subject Matter Expert to validate the rules extracted.

Actively involved with team in Auditing, monitoring, supporting, suggesting improvements and recommendations to meet client satisfaction.

Evaluated conditions for meeting the health care benefits, Medicare and Medicaid standards.

Maintained the final Business rules Documents and other artifacts produced by BA team.

Worked with QA team on client's test environment to validate the rules and maintained defect inventory.

Actively involved in meeting with Leadership team to update Project status and Project Velocity, also worked with them to resolve any blockers for the project.

Played a key role on project issues such as release management, change management, scope control, and requirement prioritization.

Actively participated in enhancement meetings and was responsible for weekly status updates, troubleshoot new releases and production issues content

Developed checklists to verify and ensure that the functional specifications are documented accurately and are aligned with Business Requirements and Security guidelines.

Performed Manual testing of the application, interacted with developers and discussed technical problems.

Conducted technical/non-technical presentations for training workshops.

Worked as a liaison between the business users and developers to clarify questions and issues related to system requirement.

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