Data Analyst Health Care
Resume:
LEELAKUMARARAJA.L
***************@*****.***,
A disciplined and self-motivated professional with 18 years of rich & dynamic experience in US Healthcare, Business Requirement Analysis, Process Management, Operations, Training, Knowledge Management, Quality and Team Management Operations in the Health Care Domain. Enhanced operational efficiency and greater customer satisfactions.
PROFESSIONAL EXPERTISE
Working as “Senior Data analyst” in Chart Analytics team. In Retrospective risk adjustment Chart Analytics team. we work with different Internal and External teams to identify medical charts most likely to support unreported diagnosis code across Medicare, Medicaid and ACA lines of business and Prioritize charts with precision for retrieval most likely to support unreported diagnosis codes. Identifying the retrieval modality deemed most likely to be successful in retrieving the medical chart in highly efficient way while maintaining coding accuracy and completeness. Work on Process Automation using Different tools like Excel Macros, SAS, Py-Spark, MS-Access, SSIS, DB Visualizer and SQL Server.
Specialties:
US Healthcare System.
Creating Fraud analytical model for one of the largest US Health Insurance company.
Data mining and assembling that enables predictive modelling
Data management and report generation for claim handling and adjudication
Expertise in health care domain, particularly, payer side payment/claim processing and automation.
Healthcare products – PPO, HMO, POS, HNO.
Functional, Technical and analytical knowledge of US Health Insurance applications
Experience in SQL server Management studio, SAS EG Program creation and execution.
Experience in DBMS Tools like Oracle Sql, PL-SQL, MS-Access, SSIS, Python and Data visualization using Tableau.
Expert in Manual Plan setup (Benefit) Configuration in Mainframe.
Expert in WellPoint Benefit Configuration in NASCO.
Expertise in Manual Testing of US Healthcare benefit plans on RUMBA Mainframe and QNXT.
Expertise in creating Facets plan benefit configuration rules.
Trained in Subscriber/Member, Claims and Providers applications in Facets
Expertise in plan building and configuration.
CBAP (Certified Business Analysis Professional) Certified by Syntel.
Payers & Health plans – Medicare, Medicaid, BCBS, Commercial, etc.
Rich Experience in Provider contracts and Claims adjudication & payment.
Knowledge in SDLC, requirement gathering.
Good experience in Process Transition Documentation (CARES).
Profile:
Have managed and led a team of 21 members, while managing successful process operations.
Hands on experience in setting up Goals for the individual team members
Trained on Facets Configuration and testing.
Expertise in Benefit Testing on RUMBA Mainframe, NASCO and QNXT
Experience in incentive calculations for monthly and annual performance reviews.
A highly organized individual who adopts a systematic approach to problem solving,
Effectively analyzing results and implementing solutions.
Excellent communication skills, people at all levels both internally and externally has ensured the development of good business relationships.
Capable of building highly motivated teams that are conscious of their part in improving productivity and quality throughout the business function.
Open to learn new technologies assign to me as and when required.
Transition Exposure:
Worked as a Manual Plan setup (Benefit) Configuration (Mainframe) process Transition Team member.
Transition Documentation for Benefit Configuration, Blue Exchange and Online Benefit Narrative process for US client (Health Care).
Strong exposure with as-Is and To-Be maps, requirements gathering, capacity planning, FMEA etc.
Identifying automation opportunities, designing and implementation of the tool.
Prepared documents for transition, ramp-up, metrics defining, tracking and reporting for which the process was awarded the “Best Transitioned Process” for Quarter 3 of 2010.
Management Skills:
An effective communicator with excellent relationship building & interpersonal skills. Strong analytical, problem solving & organizational abilities. Possess a flexible & detail oriented attitude.
Proven ability to manage with consistent results. Excellent organizational and
Analytical skills and the ability to lead projects and get results.
Adopts a systematic approach to problem solving and effectively analyses results and implement solutions.
Dedicated and committed, willing to take on challenging roles tough assignments and work to tight deadlines.
Demonstrative excellence in planning, transitioning and managing several successful processes with involvement in technological updations.
Skills in planning, expertise in tapping prospects, analyzing business requirements, rendering technical guidance to the clients.
Personal Attributes:
Highly organized and efficient, a flexible and versatile team player who will work hard and excel in any environment.
Impressive work ethic, reliable, dependable and conscious of duties and responsibilities
A positive approach to all tasks and pride in achievements has resulted in many successes. The ability to form good relationships with both peers and staff is central to my character.
Administrative Skills:
Excellent organizational skills, highly efficient and capable of completing multiple tasks at one time. Ability to use resources effectively to meet work commitments.
Organization : Optum Services Inc, Minnetonka, MN, USA
Designation : Senior Data Analyst
Period : April 2020 – Till date
Work Profile: This Payment integrity process includes Identifying Incorrect Health care payments using complex Payment Integrity rules and Identify areas of improvement within the process and prepare and implement solutions to improve the quality and productivity in the Mid-Atlantic payment integrity team. The Chart Review Analytics Process working with Medicare, ACA and Medicaid business team and Chart retrieval vendors and coding team to Identify Patients charts which is Underreported/unreported and work with analytics team to identify data issues and create reports and obtain approvals needed from stockholders. In this retrospective chart review process, we work as central point of contact between different teams to achieve highest accuracy in process withing regulatory guidelines to generate a more complete picture of member health status while maintaining coding accuracy and completeness.
Responsibilities:
Create multiple SAS Reports and Excel reports for business team to understand charts identified in chart analytics process.
Validate data values/attributes used in selection process and present it to Stake holders and obtain approvals.
Perform data and analytical services in support of risk adjustment programs, maintaining compliance with CMS standards and modeling financial impacts of changes in risk adjustment data and methodologies using Pyspark and DB Visualizer and SSMS and SAS Tools.
Handle High complex data analytical requests. Build high complex SQL queries and pull data from different environments.
Recognizing areas for automation and create automation reports using SSIS, Excel VBA Macros for Monthly standard reports and adhoc reports.
Work with Internal RPA Team to identify areas for Robotics process automation and work with RPA Team in providing inputs files and validate RPA Results and incorporate those RPA Results in reports for audit team.
Transition Excel Inventory management process to Automated SQL Process from Overpayment findings to Invoice.
Built automated Inventory reports and dashboards and notification emails for Internal and external client Leads and Managers to monitor Audit and Overpayment Findings Inventory process.
Work with business users and project managers to understand inefficiencies in existing process and Implement solutions to Improve process.
Organization : Equian LLC (Optum), Louisville, KY, USA
Period : June 2017 – April 2020
Career Progression
Designation : Senior Data Analyst – DATA MINING TEAM
Work Profile: The process of sorting through large data sets to identify patterns and establish relationships to solve problems through data analysis. Works cross functionally to uncover previously unknown patterns and trends in databases and use that information to build models/Concepts. This position requires a well-developed understanding of the health insurance/health care industry, and in-depth understanding of health care data and the methods of data analysis.
Responsibilities:
Process Automation to improve recovery opportunities, quality and Efficiency.
Maintain the standard operating procedures for backend data assets to meet both internal and external reporting requirements and build reconciliation systems aligning with Equian internal reporting across Mid-Atlantic Region.
Develop complex SQL queries for ad hoc reporting and to answer managerial questions and work closely with business owners and leadership.
Automated Several Processes and Business activities for various business systems.
Serve as a liaison between data teams and Clinical Audit team and maintain key relationships with all impacted business areas.
Develop and support innovative ETL and reporting solutions, maintain 2 clients claims data loads and load weekly/Monthly ancillary files and weekly/Monthly/Quarterly Internal/External reports generation and Development of new concepts.
Design, document, develop, code, and scalable advanced analytics solutions and Tools to identify missing opportunities.
Developing and improving processes and documentation to support best practices.
Help Team to get what they need rather than ‘just’ what they’re asking for.
Anticipate problems and proactively design solutions even before the problem is presented.
Always try to understand the process and bottle necks in a process and work with stake holders and help them in whichever way possible to speed up the process and improve the productivity and quality.
Helping team member’s complete tasks for overall success of project and displayed a strong worth ethic that effectively motivates team members to excel.
Organization : SCIOinspire Corp, Louisville, KY, USA
Period : July 2012 – June 2017
Career Progression
Lead-SIU Data Analytics: November 2013 – June 2017
Designation : Lead-SME (Onsite) – GLOBAL ANALYTICS COE
Work Profile: Research and identification of cost recovery opportunities, data analysis and related reporting. Works cross functionally to identify root cause and resolve overpayment issues. This position requires a well-developed understanding of the health insurance/health care industry, and in-depth understanding of health care data and the methods of data analysis.
Responsibilities:
Managing service delivery in SIU Data Analytics area and major initiatives across the client environment.
Ensure high customer satisfaction and be the single point of contact for client escalation.
Have an oversight and resource planning responsibility for several leverage organization delivering the services.
Take ownership of end to end delivery of services or major initiatives assigned.
Collaborates with a team to drive investigating root cause, and resolving causes of claims overpayment.
Leads and participates in the planning, analysis, development and implementation SIU DA Analytical models.
Lead-Analytics COE : April 2013 - November 2013, Chennai – 600 089.
Designation : Lead-Product Analyst – GLOBAL ANALYTICS COE
This position is responsible for building and leading a new Health Analytics Team at SCIO.
Lead the Health Analytics Team to develop and produce high quality and analytic reports of health care data.
Manage the Health Analytics Team, including prioritizing and delegating of business analysis projects.
Directly oversee the quality of health analytics performed by the Health Analytics Team.
Develop analytic standards for complex modeling, analysis, trending, interpretation, and presentation of data.
Design and manage department’s reports are developed and delivered on time and are of the highest quality.
Establish analytic techniques and methodologies to clarify data requirements assess the value of the information, analyze performance, identify risks, and make recommendations.
Provide project management, process design, and implementation for analytic projects, new initiatives, etc.
Sr.Business Analyst : July 2012 - April 2013, Chennai – 600 089.
Designation : Product Analyst – PRODUCT DEVELOPMENT
As a Product Analyst, my responsibilities included:
Gathered business requirements by conducting detailed interviews with business users, stakeholders, and Subject Matter Experts (SME’s)
Communicated and interacted on a regular basis with the project manager and development team during different stages of the project
Prepared Business Requirement Document and analyze requirements, and convert business requirements into functional specifications documents, Change request documents.
Managed schedules and collaborated with different teams working on the project
Engaged in data assembling and structuring for classifying subrogatable claims.
Providing data structure (including preparation of meta-data) to be inputted for predictive modelling to identify viable and non-viable claims.
Prepare Business Requirement Document and translate business requirements into functional specifications documents to data analysts.
Data mining and assembling that enables predictive modelling using SQL.
Prepared project progress reports and status reports and submitted to the management on an ongoing basis
Assisted with required data analysis, interpretation, correction and document presentation for various assignment
Organization : Syntel Limited, Chennai – 600 089.
Period : December 2011 – July 2012
Career Progression
Business Analyst : December 2011 - July 2012
Designation : Project Lead – HEALTHCARE PAYER PRACTICE
As a Business Analyst, my responsibilities included:
Monitoring upcoming trends in Healthcare Segment
Research on various hot button items of healthcare market
Preparing Profiling, Collaterals, assessments and Flyers
Preparing proof of concept
Gather and present Syntel capabilities and experience to clients through presentations
Supporting sales & Involving in preparing RFP (Request for Proposal).
POCs, Demos and Whitepapers, Fliers & market collateral creation
Involved in Facets configuration and testing automation proposals and POC Preparation.
Involved Provider contract standardization and smart tattoo Implementation for Blues.
Knowledge Building initiatives, support to internal healthcare certification programs
Notable Achievements:
Involved in preparing E2 level Claims management questions for assessment and research topics.
Completed SYNTEL E1 Health care certification.
Presented Administrative Simplification White paper.
CBAP (Certified Business Analysis Professional) Certified by Syntel.
Organization : Cognizant Technology Solutions, Chennai – 600 045.
Period : March 2010 – December 2011
Career Progression
Process Specialist : March 2010 – December 2011
Designation : Process Specialist – BENEFIT (PLAN) CONFIGRATION
I am presently working on a High end process called WellPoint Benefit Configuration which involves building, Configuration and maintenance of Health Insurance plans on the NASCO Model Office Mainframe system.
Involved in detailed study of plan benefits and services and Configuration it on the NASCO Model Office to achieve auto adjudication and correct pulling of benefits and payment on the claims.
Involved in the Configuration of New Groups, Maintenance and New Packages plans with different Plan sponsors.
Configuring the customer benefits through back end and front end in Facets
Building on the Product shell and Working on the Components and variable component in Medical plan application
Working on the tables like SEPY, DEDE, LTLT, TPCT, IPCD, IDCD, RCCT, SPCT and SRCT etc.
Involved in the maintenance by handling revisions and issues related to the Plan.
Involved in fixing testing and production issues.
Involved in the development of macros in the NASCO Mainframe application scripts.
Working as a Subject Matter Expert (SME) in US health insurance domain.
Involved in the training, mentoring and auditing for the Trainee Batches.
I was involved in handling and monitoring a team of 45 members.
Involved actively in weekly calls with the clients regarding quality and other issues.
Notable Achievements:
Trained 25 people in WellPoint Benefit Configuration.
Hands on experience in setting up KRA for the individual team members
Prepared documents for transition, ramp-up, metrics defining, tracking and reporting for which the process was awarded the “Best Transitioned Process” for Quarter 3 of 2010.
Preparing Weekly/Monthly Decks for Operational reviews
March 2006 – March 2010
Organization : HINDUJA Global Solutions, Bangalore – 560 068
Designation : Senior Claim Processing Executive,
Career Progression
Senior Processor April 2008 – March 2010
Processor March 2006 – March 2008
Designation : SENIOR PROCESSOR – BENEFIT (PLAN) CONFIGURATION
I am presently working on a High end process called Plan Installations which involves building, coding and maintenance of Health Insurance plans on the ACAS (Automatic Claims Adjudication System) Mainframe system.
3 years of experience in the Health care Manual Testing and Quality Assurance on the Mainframe system.
Extensive experience in preparing test plan, project matrices, test cases, defect reporting and test report.
Possesses strong problem solving, trouble-shooting & documentation skills.
Preparation & Execution of Test Cases.
Involved in detailed study of plan benefits and services and coding it on the Mainframe system to achieve auto adjudication and correct pulling of benefits and payment on the claims.
Involved in the Configuration of Renewals, New builds and New PI (Plan Indicative) plans of Plan sponsors.
Involved in the maintenance by handling revisions and issues related to the Plan.
Involved in fixing testing and production issues.
Involved in the development of macros in the Mainframe rumba application scripts.
Working as a Subject Matter Expert (SME) in US health insurance domain.
Involved in the training, mentoring and auditing for the Trainee Batches.
I was involved in handling and monitoring a team of 6 members.
Involved actively in weekly calls with the clients regarding quality and other issues.
Knowledge of HIPAA (Health Insurance portability and accountability Act) complaints of US act.
Exposure to different data formats such as UB92, UB04, HCFA (Health Care Financial Administration) 1500 standards.
As part of Knowledge Management Team to gather and update the information regarding any subject related to heath insurance domain to the team and addressing their queries.
Excellent knowledge and exposure to all hospital (Inpatient, Emergency, surgery observation and outpatient etc) and medical contracts.
Involved in giving presentations and refreshing training for the team members in handling complex topics and error prone subjects.
Expertise in subjects such as Stop Loss, Maternity, Surgery (contracts, reimbursements, modifiers involving Medicare,Medicaid and Commercial Primary claims, Insurance Plans and products, plan benefits, referrals etc.
Involved in analyzing the error trends (on a daily, weekly, monthly basis from the CAS (Claim auditing system) done by the client and preparing a work plan to avoid the errors in the future.
Data Collection of the errors committed by the examiners and present with the management.
Planning on production and manpower in Group leader absence.
Responsibilities as Processor:
Maintenance of production and Quality reports of the team.
Quality Representative of the team.
Coordinate and work with the operations in identifying the root cause for better performance
Maintenance of a Skill set Database
Creation of power tools/macros to simplify the regular processing
Handling complex claims.
Identifying Junior examiners with weak skill set and act as mentors.
Notable Achievements:
Worked my way up from Assistant Claim Processing Executive to Senior Claim processing Executive in less than two years.
Certified by client in Pittsburgh, USA for 3 months during the assignment of new module, Manual Plan Configuration.
Attended Client Training in Atlanta, USA for 3 months during the assignment of new module, Benefit Configuration.
Reward And Recognitions:
CERTIFICATE OF EXCELLENCE – For completion of ACAS Manual Plan Setup Training in Pittsburgh, USA
HALL OF FAME AWARD – Recognition given by client for achieving overall quality score of 100% for the year 2008
BUSY BEE AWARD - Recognition given by HTMT for diligence and hard work
8 TOP GUN AWARDS – For outstanding performance for 6 Months in Claim processing Department and 2 Months in Manual Plan Setup.
BEST TRAINEE – Recognition given by Client for the best trainee.
OUTSTANDING TEAM WORK – For Excellent performance within 6 months, this helps SCIO to win the other accounts from same client.
Certifications:
CBAP - (Certified Business Analysis Professional) Certified by Syntel.
PAHM - Professional, Academy for Healthcare Management from America's Health Insurance Plans (AHIP).
FAHM - Fellow, Academy for Healthcare Management from America's Health Insurance Plans (AHIP).
PHIAS - Professional, Health Insurance Advanced Studies from America's Health Insurance Plans (AHIP).
FHIAS - Fellow, Health Insurance Advanced Studies from America's Health Insurance Plans (AHIP).
ITP – Healthcare Information Technology Professional (AHIP).
Automation Anywhere Advanced RPA Certification- AA Robotics Professional Associate (AAU).
Uipath_RPA Developer Advanced Certification – Uipath Advanced Robotics Professional Associate (Uipath).
Microsoft® Certified Solutions Associate: SQL 2016 Database Development
SIX SIGMA GREEN BELT – Training and ceritified in Six Sigma Green Belt by Benchmark Six Sigma.
Best Trainee - Given by Onsite client for the best trainee in US Healthcare Benefit configuration process.
October 2001 – March 2006
Worked with SANSERA Engineering Private Limited, Bangalore - 560068
Designation: Senior Assistant (Software Department),
Second largest company in Asia to manufacture Rocker Arms. Manufactures Precision forged & machined components for the Automobile industries. Manufactures it’s own CNC – SPMs to be cost effective & enhance it’s machining capabilities.
Responsibilities:
Knowledge in Preparing MIS and Weekly Plan..
Preparing & analyzing production & quality reports on daily basis.
Knowledge in invoice Preparation in Tally 7.2
Knowledge in Software development (VB 6.0 ), database knowledge (Microsoft SQL) and Software Testing in Manual and Automation testing Tools.
Experience in System Administration.
Technical Expertise
Operating Systems :Windows 95/98/NT/XP/2007/2008
Databases :MS Access, SQL Server, Oracle EDW
Software pacakges : MS Office, VBA(Excel Macro), V.Basic 6.0, SQL, PL-SQL, SAS EG 5.1, SSIS
Lotus 1-2-3 : Lotus Excel, Lotus Word
Educational Qualification
MFM Master in Financial Management (Twinning program). From Christ College, Bangalore, Karnataka.
B.A (Economics) Passed in First Class with an aggregate of 65% from Sri Venkateshwara University, Tirupathi, Andhra Pradesh.
Place: Andover, Kansas Leelakumararaj.L
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