EXPERIENCE SUMMARY:

99 saturn sl2 car manual facets claims user manual priority downloads yamaha waverunner 800xlt manual health claims processing in the us - tm floyd & basic elctrical manual facets claims processing and ajudication system adventist pathfinder staff manual facets claims user manual compiled pdf, doc, ppt rand ts1a claims processing system. Information as the Facets manual, facets.pdf, which is in your Facets folder. Left-click on the next to “Special Topics” to expand the topic list. Then left-click on “Glossary” to display a glossary of Rasch technical words. You may find this useful if you don’t understand the meaning of a word in this Tutorial.

• Experienced in all aspects of testing processes includes Planning, Preparation, Execution and Completion.
• Deep understanding of Software Development lifecycle, QA methodologies and strategies.
• Interacted with developers in fixing the defects by verifying the logs and databases in a lot of occasions.
• Good Team player and also have ability to work independently in time sensitive environment.
• Knowledge of Waterfall, Agile SCRUM, Rational Unified Process (RUP) methodologies
• UML, QA Validations to ensure the Quality standards, Quality Assurance Life Cycle (QALC) and QA Methodologies.
• Expert in HIPAA Transactions testing and in - depth knowledge of HIPAA framework (Health Insurance Portability Accountability Act) rules for ANSI X 12 messages 83 7P, 835, 276/277, 270/271, TA1 and 997 in 40 10 to 501 0 Standards.
• Expertise in Implementing Configuration and Change management and Versioning tools like VSS, CVS, Clear Case and Pro Track, PVCS Tracker and Version Manager.
• Expertise in testing Enrollment, Billing and claims processing in FACETS
• Extensive involvement in testing Trizetto’s FACETS and mainly involved in Enrollment and Eligibility modules.
• Specialized in system study and testing Health Care, Financial, Insurance and Banking applications developed on various technologies such as Facets, QNXT, J2EE, JSP, Java, SharePoint, VB.Net, Oracle and SQL Server on Windows and UNIX environments .
• Involved in testing QNXT Member, Provider, Claims Processing ( with proper ICD - 9 and ICD - 10 and HCPCS/CPT codes), and Utilization Management, Contracts, and Benefits modules.

TECHNICAL SKILLS:

Operating Systems: MS-Windows 8/7 Professional, UNIX

Databases: Access, SQL Server 2005/08/12

Languages: SQL, HTML, Working knowledge of UNIX

Testing Tools: Jira, Spira Test, Xenu, Test Director, PVCS, Quality Center, ICU, Selenium, QTP

Software Applications: MS Office (Word, Excel, PowerPoint) IE developer tool bar

Software Testing Skills: Writing Test Plan, Test Cases, Test Scripts, Test Execution, Defect Reporting and defect tracking. Very good experience with Requirement, Test Plan, Test Lab, and Defect modules of Quality Center.

Tools: QNXT, Trizetto FACETSClinical Applications: QNXT, CCMS

Facets Claims System

Methodologies: RUP, Waterfall, Agile, Scrum

WORK EXPERIENCE:

Confidential, Manhattan, NYC

Facets QA Analyst

Roles & Responsibilities:

• Responsible for creation of test cases for business requirements and Design Documents.
• Involved in Design, Execution and updating of Test Cases for Functionality testing.
• Working on following functional Threads like Eligibility, Group, provider.
• Involving in preparing Test plans based on user requirement documents.
• Processing claims and adjudicating them as per Networx Agreement.
• Working on provider, subscriber, NetworX, Medical Fee Schedule modules.
• Processing claims to adjudicate successfully to validate whether there is any price mismatch with proper ICD 9 and ICD 10 and HCPCS/CPT codes as per Networx.
• Working on members Benefit details.
• Performed analysis on the Affordable Care Act (ACA) law & corresponding Centers for Medicare and Medicaid Services (CMS) and Connecticut Health Insurance Exchange (HIX) Business requirements.
• Conducted Regression Test for the fixes of the application.
• Validating claims based on legacy claim information by using allowed amounts based on agreements.
• Also used to process claims manually based on service category like Lab, Ref Lab, ER, ASC, PT, Certified Home Care, Urgent Care etc.
• Also working on APRDRG Inpatient claims.
• Working on Medical Networx Configuration under Networx module in Facets to gather agreement information while processing claims like allowed amount and contract terms and Pricing details to process claims and for successful adjudication.
• Good Understanding of HIPAA (Health Insurance Portability Accountability Act) rules for ANSI X 12 messages 83 7, 835, 276/277, 270/271, TA1 and 997 in 5010 Standards.
• Also verifying members class plan details, group details and benefit details.
• Responsible for modification and executing of the Test Scripts.
• Working on RQM to upload the test cases.
• Working on Clear Quest to log defects raised while testing.
• Participated and provided input in team status meetings for classification issues.
• Provided status report on weekly Basis to Management prior to weekly meeting.
• Also involving in Agile SCRUM daily status meetings with Team Lead to discuss the work status and issues.

QA Analyst

Roles & Responsibilities

• Developed Test Cases bases on Requirement Specifications and Design Documents.
• Responsible for modification and executing of the Test Scripts.
• Good understanding of HL7
• Involved in testing QNXT Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits with proper ICD - 9 and ICD - 10 and HCPCS/CPT codes.
• Involved in manual claims Adjudication process.
• Creating, Approving and Modifying PA in both Portal and QNXT.
• Involved in Adding Contracts to the Provider in QNXT and associating Providers in Portal while creating claims.
• Involved in Functional, Integration, and Regression testing of the application.
• Processed Medical claims and applied edits to the claims for testing purposes
• Involved in Processing QNXT 837 Healthcare Claims (Institutional and Professional) in PORTAL with valid TPI.
• Worked in utilization management module for to create and test PA.
• Involved in uploading and processing of EDI 278, 276 claims in Portal.
• Prepared sample EDI test sets for files like 276/77, 278,837 and followed HIPAA implementation guide in preparing them.
• Also used BizTalk server as middle ware server to see responses for X12 files like 835.
• Coordinated with offshore people and updated the tasks to manager.
• Worked with stakeholders in UAT environment to ensure Business requirements are tested properly.
• Used RMT for running the tasks like uploading, modifying, executing and taking logs accordingly.
• Updated status report on weekly Basis and submitted to the team prior to weekly meeting.
• Participated actively in conference calls, project meetings and delivered input.

Environment: ASP.NET, VB.NET, QNXT, DB2, Oracle, SQL, QNXT, UNIX, Windows, Clear Quest, RMT.

Confidential, Michigan, MI

Business Analyst/QA

Roles & Responsibilities

• Conducted one on one sessions and team meetings with the team leads and SME’s to understand the business requirements.
• Preparing System Test Cases from functional and technical requirement and Use case documents and performing System Testing.
• Troubleshoot file transmission problems and assisted customers in a call center environment with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (837P, 837I, 837D, 270/271).
• Understood the healthcare plans offered, including Medicaid Managed Plans such as Children and Adolescent Care, Women’s Preventive Care, Maternal Care, Asthma Care, Diabetes Care, Cardiovascular Care, and Mental Health.
• Defined overall Architecture for EDI transaction for real-time and batch process
• Have worked with Chevron, delivering Regulatory (EPA) Reporting strategy for Corporate Health & Environment Safety.
• Implemented RUP and followed iterative, Use Case driven process for requirement documentation and deployment.
• Involved in making Use Case Diagrams, Activity Diagrams, and using analysis and design models tools like MS Visio, Rational Rose through RUP, Agile and Waterfall Model
• Worked with SME close to understand Claim Adjudication Process setup in Facets.
• Followed the standards of PMO which included getting approvals for SOX Compliance at various Gates.
• Responsible for Medicaid Claims Resolution/Reimbursement for state health plans using MMIS.
• Prepared the Charter/BUR and functional design document.
• Monitor departmental policies, processes, and procedural compliance for both in-house and client sites to ensure proper adherence to budget and safety standards
• Experience with Medicare and Medicaid: Claims processing, Membership, and Eligibility Verification and care management.
• Thorough knowledge of Eligibility and membership Affairs. Also knowledge of HIPAA, X12, and HL7 standards and Medicaid provider best practices.
• Updated the functional design document for NPI related changes in the Encounters project.
• Applied Unified Modeling Language (UML) methodologies to design Communication Diagram, Use Case Diagrams, Activity Diagrams, Sequence Diagram, ER diagrams & Data Mapping
• Analyzed encounters claims file (837 P, I, D) using Spec Builder.
• Created SQL queries to check the updates in Oracle database and executed SQL queries in Oracle to check the redundancy of data. Setup runbook for Inbound and Outbound EDI transactions.
• Developed business level activity diagram utilizing UML (according to Agile Unified Process) to visualize use cases, identified gaps between the current model and future model.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Conducted JAD sessions with the participation of the users and the stakeholders to gather requirements.
• Utilized corporation developed Agile SDLC methodology. Used Scrum Work Pro and Microsoft Office software to perform required job functions.
• Trained new Business analysts about the system and the data model.

Environment: MS Project, Windows, Microsoft Office SharePoint Server 2003, Agile, Microsoft Content Management Server, ASP .NET, IBM DB2 data server, MS Office, MS Visio, Test Director.

Confidential, Kalamazoo, MI

Business Analyst/ QA Analyst

Roles & Responsibilities

Facet Health Care Claim Processing

• Developed on overall project plan and implementation schedule through consultations with project team, management, employees and external consultants.
• Documenting the objectives, constraints and scope of the system
• Worked on JIRA on defect management and for Business Process Modelling.
• Used the agile methodology guidelines to carry out every step of the business modeling process.
• Assignment was to develop applications under Agile Scrum master.
• Extensive knowledge of implementing software development projects using Agile/Scrum
• Prepared the Functional specifications, and tested the interfaces.
• Maintaining the Requirements Traceability Matrix (RTM) across the deliverables of a project
• Designed Data Flow Diagrams (DFD’s), Entity Relationship Diagrams (ERD’s), and various UML diagrams using enterprise architect.
• Involved in defect review meeting and wrote product documentation
• Involved in writing Test Cases, procedures, reports and approval of software release.
• Created test cases and scenarios for Unit, Regression, Integration as well as Back-end, GUI and Black box testing.
• Involved in analysis of Test Plans and Test cases, detecting bugs in the system, preparing the Defect reports using Test Director and interacted with developers for Debugging.
• Wrote SQL statements to extract data from the Tables

Facets Claims Processing Pdf

Environment: Windows, Enterprise Architect, Jira, Zachman Framework, Unix, Win Runner, Load Runner, Test Director, PL/SQL, SQL, VB, ASP, VB script, Java script, HTML, SQL server, Oracle and RUP.