Raju Jilhewar

Analyst Integration Quality

Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Having overall 11 years of experienced in Healthcare Domain in IT Industry includes various challenging roles in Manual Testing over 6 yrs and Claims counter part 4.5 Yrs of experienced using various Platforms and tool, Perform Application testing and Contract and Benefit configuration Testing in US Healthcare Domain. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

Skills

Technical skill: Software Testing Life Cycle, Software Development Life Cycle, Black Box Testing, Functional Testing, Agile Methodology, API Testing Programming Language: Java, HTML, JavaScript

Data Base: SQL Server

Utilities: Facets, Aldera,Jira,MS Excel, MS Word, MS PowerPoint, Notepad++ Language: English, Hindi, Marathi

Other: Active Team Member, Problem solving, Professional strong work ethic

Work History

2016-12 - 2023-01 Analyst Integration Quality

Evolent Health International, Pune

Project: 1 Manual Testing – Bright Health (Benefit Testing) Period: Oct'22 – Jan'23

Understanding Client Business Requirement.

Worked on Client requirement Benefit Grid/Jira Ticket analyzed client requirement and raised any query or requirement gap related. Part of Test planning and project estimation.

Resolved any requirement blocker in daily scrum meeting . Write test cases base on requirement by creating scenarios. Doing testing on Aldera platforms.

Execute all test cases on Jira Test management Tool Create defect/bug for all failed test cases on Jira Tool Follow Defect life cycle till defect get fixed Hands on experience on Functional Testing, Regression testing, Retesting,Smoke Testing, Sanity Testing, System testing and UAT Testing. Pune, India 411001

883-***-****

adxnhv@r.postjobfree.com

Hands on experience on Cost share testing, Claim Counting Rule (CCR) Testing, Benefit Rule service testing, Plan termination testing Monitor product reviews promptly and regularly inform development teams if any changes are needed in product.

Supporting to team in peer review and Monitoring new or changed client requirement.

Sending daily status & Weekly status summary to Claim Integration Team.

Delegating all fail test case report and testing all test cases on Visium to verify root cause for fail test cases and execute all those test case manually.

Project: Manual Testing – Bright Health (Contract Testing) Period: Sep'16 – Sep'22

Understanding Client Business Requirement.

Working Contract Reimbursement Schema.

Executing & Analyzing the test Scenarios.

Testing all the Contract & Test Cases fail through JIRA. Doing Claims Testing using Visium Tool to ensure claim having correct benefit per reimbursement schema. In case not having correct benefit then using correct data for the testing to get result as expected. Delegating all fail test case report and testing all test cases on Visium to verify root cause for fail test cases and execute all those test case manually.

Supporting to team in peer review and Monitoring new or changed client requirement.

Hand-on experience in handling different types of CPT/HCPCS codes, Diagnosis codes, DRG and Revenue codes Worked on different kind of CMS and client custom fee schedules such as Physician Fee schedule, DME, Clinical Lab, Anesthesia, ASP drugs etc. Creating various reports such as Daily Status Report (DSR) and Weekly Status Report (WSR) and presenting at management level.

2014-04 - 2016-04 Sr Associate

Trizetto A Cognizant Company, Pune

Projects Claims Project- Memorial Hermann

Role: Sr. Associate Period: April'14-April'16

Hands On experience of Facets Testing.

Tested Facets Module- Member, Claims Working on Memorial Hermann on UAT testing End to End Testing Mapping Provider contract affiliation, Provider network affiliation, Claim Benefit, Fee schedule rate, Pricing calculation.

Mapping Member Accumulator per Member Benefit Grid Member Out of pocket, Individual deductible, Family deductible and Copay, Coins etc. Verifying and validating Member Plan affiliation and mapping member benefit configuration per Member Grid

Identifying trends and potential critical issues that impact across line of business.

Analysis, triage, bucket and score tickets through series of fields within JIRA.

Providing input to standing up an automated prioritization Process. Hands on experienced service configuration & Validation, Code Limitation, Provider Network, Member Plan, Pan strategy Ensuring that supporting documentation/source documentation is included as part of the requirement gathering including escalating when additional meetings/workshops.

Conducting peer reviews on design documents as required. Retrieve Claims process data for prior month from Facets.

Delegate Tickets & claims among team per the client requirement. Verify Member & Provider Demographic information Verify Provider & Contract affiliation for audit perspectives Reviewing Member accumulator & Benefit grid to verify correct benefit. Audit the configuration for each claims, for Remark code, claim line pricing, Fee schedule, Payer compass Pricing get done correctly or not. Finding configuration glitch & Payer Compass pricing issue. Create TSO ticket for all the Configuration and Claims error once the issue gets fixed 2011-06 - 2014-03 Associate

Trizetto A Cognizant Company, Pune

Project 2: Facets Claims Project- Lovelace Health

Role: Associate Period: Jun'11-Mar'14

Conducting various training and session to improvement of process Supporting process Manager and Supervisor Operational activities. Hands on experience performing various task on Facets Platform. Experienced on Claim adjustment, Customer service task workflow. Allocate daily work among team and track daily and weekly report Given process and application training to new joiners End to End Processing of claims per client Guidelines.

Experience on processing Professional (CMS-1500) & Facility (UB-04) Claims Knowledge about Verifying Member Demographic & Provider Demographic Information on Paper on EDI Claim image. Experienced in handling claims like COB Claims, Corrected Claim, Customer Service Task, Authorization & Duplicate claims.

Hands on experience working on Medicare, Medicaid and Commercial plan Claim.

Education

2008-08 - 2010-08 Master in Computer Management: Commerce & Computer Information

Nagpur University - Bhadrawati

Accomplishments

Best performer awards received 2 times in Trizetto A Cognizant Company.

Star Performance Award 2 Times & 1 Time Pat On Back Award in Evolent Health International

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