Accomplished PM/BA skilled in achieving operational efficiency in the health care Insurance and Pharmacy Benefit Management. Performed Business process improvement, data analysis. Experienced in Government Healthcare Insurance related projects (PBM
Implementations, Medicaid Expansion) and other data-conversion projects. Experienced in data mapping and user acceptance testing, as well as solving complex problems in high-pressure environments. Excels at cultivating, managing and leveraging client relationships.
Business Architecture: Analysis,
Business Case, Business Requirements, Functional Requirements,
Entity-Relationship, and Cost-Benefit Analysis
Technical Delivery: Business
Requirement, Technical Design, Test Plan, Implementation Plan, Defect Tracking,
Prioritizing, Root-cause analysis, Incident Management, SLA.
11i, SQL Server 2012, MS Access, Db2
Operating Systems: UNIX,
Process Flow: UML,
Rational Rose, MS Visio
Suite – Clear Quest, Rose, Requisite Pro, Visual Source Safe, Microsoft
SharePoint, Team Foundation Server, JIRA, Mercury Quality Center, CA – Service
Productivity Software: Microsoft
Project, Visio, MS Office
Project Manager /Sr Business Systems Analyst09/2015 to CurrentHealth First Health PlanMelbourne, FL
Health First Health Plan (HFHP) is switching its PBM vendor from CATAMARAN to Express Scripts Inc.
ESI) and moving all its pharmacy benefits operations to ESI from 1st Jan 2016.
The Project is to migrate the Member / Groups / Benefits / OOP/ Rebate Data maintenance between HFHP and ESI and provide training and assistance to the HFHP associates during the implementation period.
The DST Health Systems is the Technology Vendor for the HFHP and providing all the backend support for PBM vendor switchover.
Coordinated with multiple stakeholders of the projects (ESI , HFHP and Technology Vendor (DST health solutions)) during implementation meetings and assigned work to development team Prepared Projects plan and defined the schedule of the project.
Prioritize change requests identified and make sure to adhere to the timelines promised.
Managed project risks, issues/problems, and activity progress to ensure project goals are achieved.
Assist with problem resolution or risk mitigation as needed.
Provided status report on a weekly basis to the senior management on the project status and health.
Developed and managed work breakdown structure (WBS).
Conducted project status meeting to track the progress of the project.
Project reporting - communicated project status to management and stakeholders.
Conducted JAD sessions with business and elicited the Coordinated with Testing team to manage the Test cases Wrote BRD and Data Mapping documents for the Commercial, Medicare and Exchange data exchange Eligibility files.
Defined the Requirements for the Inbound and Outbound RX and Medical Accumulator and Group Structure / Benefits Plan Level (BPL) of the Member and Wrote BRD and Mapping documents for the development Team.
Environment: SQL Server, Microsoft Word, Excel, PowerPoint, MS project, SharePoint, Visio.
Project Manager / Sr Business Systems Analyst05/2015 to 09/2015TEKsystems IncBoston, MAFMC is being rated on their quality
measure by the CMS and being penalized for bad rating. The QIP SAS conversion
project calculates the five star rating before the data submitted to CMS to
avoid penalties and provides information to Business for appropriate decisions
and reviewed the existing process and prepared scope and vision document
of the project.
Projects plan and defined the schedule of the project.
Conducted project status meeting to
track the progress of the project.
Project reporting – communicated
project status to management and stakeholders.
Risk, issue and resolution –
mitigated risk, managed issues and provided resolutions to stakeholders.
Conducted JAD sessions with business
and elicited the requirements.
existing SAS code and prepared data flow diagrams to define the technical
BRD and FSD to get sign off from stakeholders.
Environment: Oracle, SAS, Informatica,
Microsoft Word, Excel, PowerPoint, MS project, SharePoint, Visio
Sr Business Systems Analyst06/2008 to 05/2015WellCare Inc.Tampa , FLWellCare
provides Medicare and Medicaid managed-care health plans to its members.
Wellcare Health Plans, Inc. is the holding company for subsidiaries WellCare,
Staywell, HealthEase, Harmony, and 'Ohana.
CMS Audit 2015 Process
CMS Audit 2015 Process Automation Project developed a new user-friendly
application for the pharmacy business group to extract data from the existing
members' prescription-drug-related database in the file format mandated by CMS.
Led the effort to gather member data
from the various IT departments (DMR, Appeals, and Enrollment).
Performed the gap analysis to find
the identified changes in the existing applications
Wrote BRD/FSD to describe the
requirements and functionality of the application
session to elicit complex requirements from SMEs and key stakeholders.
Wrote technical design document for
development team to use to write the code in SQL and SAS for backend.
Coordinated with QA to perform the
Provided status reports to management
team of the project.
Tracked assigned tasks of the
Resolved conflicts during the
Environment: ORACLE, SAS, MySQL,
PLSQL, Cognos, Microsoft Word, Excel, PowerPoint , MS project, SharePoint , Visio
DER Modification Release
Workflow tracks prior authorizations (coverage determinations) required for
special formulary and non-formulary drugs. WellCare gets these authorizations
by fax and web submission. Upon receipt, the pharmacy business has 24 to 72
hours to approve or deny the authorization, based on line of business (Medicaid
or Medicare) and urgency of need. Based on the decision, the members and
providers are notified by automated or manual calls, faxes and letters. As part
of Release 3, the DER application added functionality to provide partial
approvals, withdrawal and dismissal on a requested drug.
BRD/FSD/TDD to describe the requirements, functionality and design of the
DER application changes.
Conducted requirements gathering
session to elicit complex requirements from the pharmacy technicians and key
Coordinated with QA to performthe
Environment: ORACLE , SAS , MySQL,
PLSQL, JAVA, JBPM, Spring
PBM- Pharmacy Benefit
Management Application changes
Pharmacy Benefit Management Application gets member eligibility data from
member database systems and produces the member eligibility files in text
format for CVS and Walgreens for these business segments: Medicare Members data
for CVS Pharmacy (stores), Medicare Members data for CVS mail order Pharmacy, Medicaid
Members data for Catamaran (Walgreens), Health Information Exchange (HIX)
Members Data to CVS and Catamaran.
Managed production scheduled
automated jobs to make sure member data was being correctly transmitted to
Supported application during break
Provided PBM SME-support to
BRD/FSD/TDD to describe the requirements, functionality and design of the
changes in the PBM application.
Coordinated with QA to perform the
Environment: Oracle, SAS, PLSQL
Health Insurance Exchange
(HIX) Integration Project
for managing outstanding risks, issues and defects and ensuring these were
successfully addressed and closed.
complex multi-party relationships involving pharmacy business, Pharmacy
IT, Enrollment IT, DELL and Accenture to ensure that the responsibility
for resolving issues was correctly identified and action taken by the
Responsible for analyzing migration
business requirements and devising appropriate solutions. This included
technical requirements, member- experience issues, legal, regulatory and
compliance requirements and operational-exception processes.
Managed the successful integration of
HIX Pharmacy benefits-eligible membership to existing applications. This involved coordinating activities
performed by DELL, Accenture and pharmacy business to ensure all
regulatory requirements met before the integration
Managed relationships with key
stakeholders at all levels within Dell, Accenture, pharmacy business and
third-party vendors (CVS, Catamaran).
Ensured that all integration
requirements were captured, risks and issues were identified and resolved
and that key pre-integration activities were executed.
Determined requirements for go live
testing and provided troubleshooting support during the launch of the HIX
Business / Functional / Technical requirements for the projects in the
area of Pharmacy Benefit Management (PBM).
Studied SAS /SQL code to define the
technical design specification
Provided support to development team
to coordinate with business, QA, infrastructure support team
Led JAD session to define the complex
requirements and suggested solutions
Performed code verification for
changes to existing application code
Worked with QA and checked in the
requirements in HP ALM
Performed validation for business
stakeholders during critical issues and deployment
Provided support to development team
during the code release by managing the pre-requisites and post-requisite
activities during the planned and Sev 2 release windows.
Suggested strategic initiatives to
improve existing processes and resolve the ongoing issues
Provided support to the management
team during the project life cycle by providing the Visio diagram and
Suggested consolidating the various
projects for PBM into single request for faster delivery.
Windsor PBM and MOOP
(member-out-of-pocket expenses) application projects. Wrote BRD, FSD and
participated in the other project-related activities.
New Jersey Healthfirst
Integration Project (Medicare and Medicaid – Duals)
Participated in the PBM and
MOOP-related activities and wrote BRD, FSD and supported the project
members during both the release and post-production cycles.
New Business Integration - NY FIDA
Project (Dual Members) –Supported project during the release cycle.
CVS Mail Order Project (Medicare)–
Supported project during the release cycle
CVS Mail Order Project (HIX) – Wrote TSD and supported project
during the SDLC process.
Maintained good relationship with
business partners by meeting their expectations.
Communicate partnership goals
effectively to build relationships with different business groups.
Consulted with business stakeholders
in the early stages when their decisions and actions affected IT area.
Encouraged business partners to learn
the new combined process (IT & Business) to improve organizational
Maintained clear, logical, effective
interaction to commutate concerns, issues and repercussion of customer
decisions to partners.
strong written/verbal communication and presentation skills while working
on the projects.
Drafted messages to fit the
business-domain expertise of the audience and the nature of the issues
Provided detailed information to
clients and offered recommendations based upon best practices.
Study facts, constraints, issues,
dependencies to decide the future course of action
Successfully completed the assigned
projects on schedule by taking ownership and sail them through QA and UAT
Supported post-production issues with
higher priority and help the team for their resolution.
Managed assigned work priorities
according to project's goal.
WellCare has expanded its new
business in the Commonwealth of Kentucky starting from Feb, 1 2012 to
implement Medicaid insurance. During this period following tasks were
executed to deliver the project
Developed many BRDs for Kentucky
Medicaid Expansion Project with high quality and within tight deadlines:
Provider File BRD, (2) TPL Outbound
File BRD, (3) Periodicity Letters BRD, (4) DER Add LOB BRD, (5) Denial
Letters BRD and others
updates eligibility of their members through Passport file received from
PASSPORT.COM for the DUAL (Medicaid & Medicare) membership. This project
will update the eligibility of members from the Passport file in the code
Provided solution and wrote Technical
Requirements for the project and received the following comment from the Vice President.
you for your work on the D-SNP eligibility automation project. This was a cornerstone of the corrections
we had to make to be in compliance with our D-SNP eligibility
checking. I know you guys put this
on the fast track, but you were still thoughtful and thorough even while
moving extremely quickly. You made
sure everything was technically correct, but helped us work through a
number of business issues along the way.
In short, you were an excellent example of how IT can be a true
Hawaii Medicaid Expansion
WellCare has launched the new
business in the State of Hawaii starting Feb, 1 2009 to implement Medicaid
During this period the following
sub-projects were executed to deliver the task.
Card Process (Enrollment): Wrote Business Requirements for the ID
Card distribution to the Members, Conduct JAD session with business
(Head of Household) Welcome Kit Process: Wrote Business Requirements for
the Welcome kit sending process to the Head of Household of the family. Coordinated
with Product Management to define the Layout of HOH
Setup (Encounters): Wrote requirements for the synchronization of
provider data from State of Hawaii.
Analyzed the solution and wrote Technical Requirements for the
Re-insurance agency of state of Hawaii.
Wrote Technical specifications for Generating the Letter.
& Medicaid Nightly Reconciliation: Drew Visio Diagram & Wrote
Technical specifications for Nightly Recon Project.
Lead EDW Business Analyst 05/2008 to 12/2008BCBS FL- Life & Specialty Venture Jacksonville, FLLSV
is subsidiary of Blue Cross Blue Shield of Florida and provides life insurance
and other specialty products to its members
Performed data profiling in the
source systems required for LSV system
the complete process flow to describe program development, logic, testing,
and implementation, application integration, coding.
Worked with internal architects to
assist in the development of current and target-state enterprise data
with project team representatives to ensure logical and physical data
models were developed in line with corporate standards and guidelines.
Involved in defining the
source-to-target data mappings, business rules and data definitions.
Responsible for defining the key
identifiers for each mapping/interface.
Responsible for defining the functional
requirement documents for each source-to-target interface.
Documented, clarified, and
communicated requests for changes with the requestor and coordinated with
the development and testing team.
Documented data quality and
traceability documents for each source interface.
Designed and implemented data
integration modules for Extract/Transform/Load (ETL) functions.
Participated in data warehouse
Worked with various ETL, data
warehousing tools and concepts.
Documented the complete process flow
to describe program development, logic, testing, and implementation,
application integration, coding.
Worked with project team to ensure
that logical and physical ER/Studio data models were developed in line
with corporate standards and guidelines.
Environment: Oracle 10g/11g, MS Access
2007, MS Excel 2007, MS Word 2007, MS Outlook 2007, Crystal Reports, PowerPoint
Development Manager/ Business System Analyst08/2002 to 09/2003UPMC Health SystemPittsburgh, PAUniversity
of Pittsburgh Medical Center (UPMC) is an $8-billion global nonprofit health
enterprise with 50,000 employees, 20 hospitals, 400 outpatient sites and
doctors' offices, and a 1.3 million-member health insurance division.
Prepared scope documents for RFP to
purchase customized solution for identity management and context sharing.
Performed the gap analysis and
identified the needs and requirements using structured approach of
requirement gathering using Rational RequisitePro.
Analyzed workflow (requirements,
analysis, design, implementation, testing) and system needs for conversion
and migration of the existing applications to the new system.
Defined and designed the web-based
system for collecting the information using an online form.
Environment: ASP, VB, IIS, SQL Server 2000