Manual Tester Service Representative

Professional Summary

Around ** years of diverse experience in Health care industry as a Business Analyst, Manual tester and Provider Credentialing Analyst. Excellent analytical and problem-solving skills in developing and implementing innovative business process and providing system solutions using new approaches.

Conversant with all phases of Software Development Life Cycle (SDLC), involving initiation, system analysis, design, development, testing and implementation. Using Waterfall, Scrum, Agile methodology.

Expertise in Requirement elicitation techniques like Interviewing, Questionnaires, focus groups meetings, structuring meetings

In Depth understanding of the AS-IS and TO-BE business processes and reviewing documents from legacy system.

Worked closely with Scrum Master, Developers and Validation team to run Reports.

Efficient in documenting Design Specification Documents, which in turn helps in transforming to Technical Specification Document.

Excellent in performing GAP Analysis and SWOT Analysis to check the compatibility of the existing system infrastructure with the new business requirements and evaluated the benefits of new system.

Created Wireframes and User Interface Documents for better visualization and understanding of the software solution using programs like Visio.

Great understanding and hands on experience with User Acceptance Testing (UAT), Root Cause Analysis, Process Design.

Tracking and managing requirement and using Requirement Traceability Matrices (RTMs) that controls numerous artifacts produced by the teams across the deliverables for a project.

Highly motivated team player with excellent problem solving, team building, judgment and decision-making skills.

Excellent knowledge on Provider credentialing, re-credentialing, Provider Recruiting and Health Insurance business process.

Well versed with CAQH (Council for Affordable Quality Healthcare) and NCQA (National committee for quality assurance), JACHO (Joint Commission for Accreditation of Hospital Organizations-Ambulatory Care division) guidelines.

Education

Bachelor’s in Computer Applications -2005 Andhra University

Master’s in Business Administration-2007-ICFAI University India

Master’s in Healthcare Management. -2014-California University of Management and Sciences -USA

Executive PhD in Information Technology 2019- Pursuing University of the Cumberlands.

Technical Skills

Microsoft Technologies

Microsoft Project, MS Office Suite.

Languages/Standards

SAS, SQL

Defect Tracking Tools

JIRA, Version One, VSTS,Azure Devops

Content Management Tools

MS SharePoint, Confluence.

Business Modeling Tools

MS Visio.

Graphic Tool

Smart Draw, SnagIt.

Project Design Methodologies

Unified Modeling Language, Use Case Development

RDBMS

Oracle, SQL Server.

Professional Experience

Client: UPMC

Role: Sr. Business Analyst /Manual Tester

Duration: July 2017 -Current

The UPMC Health Plan Provider portal helps the providers to view up-to-date eligibility, PCP information, and covered benefits. The portal lets Chat with a UPMC Health Plan provider service representative in real time, and 24-hour access to claims information.

Responsibilities

Interacted with Product Owner, Customers and Project team members in analyzing the User stories and acceptance criteria.

Involved in Requirement gathering, and Preparation of test cases based on Product Backlog.

Experienced in the creation of use cases and the development and maintenance of test

specifications, test cases, test scripts and test data

Extensive knowledge of SDLC (Software Development Life Cycle) methodologies.

Experience in working with agile methodologies and active participant of SCRUM meetings.

Experienced in various types of testing including, System Testing, User Acceptance Testing

(UAT), and Ad-Hoc Testing, of Web Based and Client-Server applications.

Strong experience and understanding of Medicaid and Medicare Services in health care

industry, claims management process.

Good knowledge of HIPPA compliance life cycle, insurance regulations and HIPAA 837 transactions.

Working knowledge of creating different types of test reports through VSTS.

Participated in design walkthroughs with various teams that has interdependencies with provider online portal.

Worked closely with developers on internal chat tool enhancements and performed testing for the whole module.

Documented provider online user guide and security principles for the portal.

Worked closely on integration of Healthplanet tool that is used for interaction members, providers and utilization of management cases.

Worked on enhancing security features to the provider portal and managed Online Administrative system for giving role-based access to portal.

Environment: Agile methodology, Windows, MS Office, Cactus, Citrix, MS Visio, HIPAA, UML, SQL, VSTS.

Client: New York Medicaid Management Information System

Role: Sr. Business Analyst

Duration: September 2016 -May 2017.

The New York State Department of Health (DOH) will be transitioning to a new Medicaid System and a new fiscal agent Xerox State Healthcare, LLC.NYMMIS will utilize a web-based core platform called Health Enterprise(HE), configured to meet New York States requirement. HE uses a web native architecture that is scalable to serve future now.

Responsibilities

Participated in design review meetings and translated the requirements to the developers and guided the team when issues related to business requirements arose.

Maintained various versions of the documents generated during the project using IBM Doors and Blue works.

Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirement

Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance to test the performance of the application from various dimensions.

In-depth knowledge on schema description, and mapping data from physical and logical data models.

Ensure that all documentation starts from baseline and adheres to standards and communicate back to base team suggestions for changes or enhancements to standard documentation.

Interacted with the developers, Validation team and Product owners on resolving the reported bugs and various technical issues.

Used Agile Development methodology throughout Project Life Cycle.

Rendered support to staff and affiliates towards the completion of the project as per the Deadlines.

Responsible for managing the documented system requirements and Requirements Traceability Matrix.

Environment: MS Office, IBM-Blue Works, Version One, Jira, IBM-Doors, Oracle, SharePoint, Nymmis platform.

Client: Verifpoint /Credentals services

Role: Sr. Provider Credentialing Analyst

Duration: November 2014- September 2015

Verifpoint is a leading Credentials Verification Organization (CVO) offers credential verification services to improve and expedite the credentialing process of healthcare providers. Fully certified by NCQA (The National Committee for Quality Assurance) and accredited by URAC, Verifpoint provides primary source verification that meets industry and regulatory standards such as NCQA, TJC, URAC, CMS and AAAHC. Beyond these standards, Verifpoint offers customized credentialing services such as abbreviated credentialing consisting of any number of elements like License Verification only.

Responsibilities

Processing initial credentialing and re-validation applications accurately and in a timely manner for individual providers groups and entities

Complete all new and established Physicians/Groups applications request forms in accordance with policy and procedure within Medicaid guidelines.

Communicate efficiently with providers and payers Market contacts with updates on enrollment request and/ or changes needed.

Analysis, review and processed providers mailing applications ensure appropriate signatures and necessary certifications are sent accordingly to payers.

Performs follow-up with insurance payers via phone, email or website to resolve provider enrollment issues.

Analyze and determine validity and accuracy of information provided on applications submitted by providers

Verifying potential and existing provider's licensure, background and other eligibility criteria as required

Maintaining credentialing information while Meeting required turnaround times and accuracy rate

Responding to and resolving problems with provider enrollment related to denial of provider by working closely with all levels of administrative and enrollment relations personnel as well as network representatives.

Environment: MS Excel, MS Office, MS Access,Windows XP/2000, Apex, Cactus.

Client: Apollo Health Street (Humana Insurance Dept)

Role: Sr. Process Associate/ Business Analyst

Duration: May 2008 - March 2014

Humana is one of the nation's largest publicly traded health benefit companies. Humana offers coordinated health insurance coverage and related services to employer groups, government-sponsored plans, and individuals. This project involved in recruiting new physicians into Humana network, verifying all the necessary documents of insurance and authorization verification. Maintenance of credentialing databases, online system, ensuring timely renewal of license and certifications.

Responsibilities:

Expertise in ensuring compliance of Initial credentialing / re-credentialing files.

Responsible for preparing and facilitating credentialing verification files for committee presentation and approval.

Took care of Accreditation, submissions, surveyor interviews and actively participated in the file review meetings.

Performed monthly quality audit reviews and appeals.

Provided quality and coaching feedback sessions to the credentialing coordinators.

Ensured the accuracy of data integrity elements with the credentialing files.

Ensured that Credentialing/ re-credentialing compliance metrics are met with NCAQ. JACHO guidelines.

Collaborated with management to review, develop, and implement new workflows.

Collaborated with management to provide performance appraisals scores to the team.

Prepared malpractice files for committee review regarding the providers’ sanctions and adverse actions.

Coordinated new hire training and development materials.

Developed and maintained training materials for quarterly refresher training.

Thorough knowledge on Primary source verification of the Providers like Education through National Student Clearing House, DEA, CDS, Specialty boards and, Sate License through state regulatory boards, and Secondary verifications like hospital/IPA (independent practice association) affiliations, Work history, through CAQH website.

Prepared Welcome/Denial Letters to practitioners completing the credentialing process.

Reviewed physician applications for completeness of credentialing policies and procedures.

Handled Executive phone and written inquiries to providers.

Responsible for documenting criminal background verification of physicians, Nurse practitioners, and physician assistants. Also, responsible for authorizing delegated credentialing.

Environment: MS Excel, MS Office, Windows XP/2000, Apex, Provider Single Point Plus.

Santoshi Tanikella

626-***-**** *****************@*****.*** Pittsburgh, PA

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