Mr. Nepal is a Perceptive IT professional with extensive experience leading cross-functional teams through the software development life cycle utilizing Agile methodologies to meet business objectives and satisfy customers. Skilled in managing multiple projects in fast-paced, team-oriented, and collaborative environments. Broad experience across multiple industries (e.g., Finance and HealthCare). Dedicated to maximizing impact of key performance metrics to enhance and expand business operations. Known for leveraging both macro and micro-scale analyses to generate holistic images of ongoing business operations for immediate actionability.
The focus of the project was upgrading and enhancement of Medicare Quoting Engine.
· Collaborated with the Program Manager to support the growth of the business from $2Million to $4 million annually over a period of 2 years.
· As a Project lead helped in the Implementation of Magellan Rx Medicare Quoting tool (Medicare Quoting Engine – MQE) which was responsible for helping customers choose between the best Medicare Advantage Prescription Drug (MAPD1, MAPD2 and MAPD3) offered to them.
· Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims), and 835 (Claim Payment/Advice).
· Responsible for claim adjudication like Medicare claims, professional claims, institutional claims.
· Dealt with the EDI transaction-835 claims payments and remittance advice, which deals with the payment from payer to provider.
· Authored Companion Guide to support all the information needed to process HIPPA transactions.
· Responsible for the development, implementation, day-to-day processing, and performance of all encounter files for specific clients.
· Thoroughly and accurately researched, reported on and document encounter claims that were processed by the MCO (Managed Care Organization) and submitted to the company.
· Served as liaison between departmental team business owners, end users, IT, Claims and Clinical departments.
· Interfaced with clients and customers (internal and external) by telephone, correspondence and/or in person to answer inquiries and resolve concerns.
· Queried data warehouse and internal databases and prepared user-friendly reports according to requestors' requirements. Developed internal algorithms, condition-action tables and decision trees and tables that incorporate member's personal and medical information.
· Created and maintained internal management tools and databases to support CQI (Continuous Quality Improvement), rates, workflow business rules and system configuration, reimbursement and documented management requirements.
· Actively involved in the creation of a comprehensive resource center through collection, documentation and extensive editing of relevant medical literature.
· Conducted root cause analyses, gathered data to pinpoint problem areas, validated that the analysis is data driven, recommended and implemented solutions and evaluated those results, and implemented controls to monitor consistent use of the solution.
· Met with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Technical Requirement Specifications.
· Gathered Business Requirements, analyzed data/workflows, and defined the scope.
· Extracted, discussed, and refined business requirements and developed a comprehensive business requirement document (BRD).
· Developed Software Requirement Specification (SRS) document using Visio and MS Office.
· Extensively interacted with both the business team and development team in coming up with Sequence diagrams.
· Generate queries and data dictionaries, analyze data and create visualization/ dashboard related to audience and direct-to-consumer insights working with data sets.
· Work closely with the development team to manage data warehouse, facilitate meetings and manage any new requirements/backlogs.
· Using AWS Identity Access Management (IAM) grant user access to certain resources by setting permissions using the described policies set within the organization.
· Familiar with all the features of AWS IAM – setting Multi-factor Authentication (MFA) for privileged users granting access to read/write/download/delete files stored in S3 buckets.
· Experience Using CloudWatch to monitor services provided by AWS of nearly anything inside or outside AWS.
· Configure alarms in CloudWatch, so that when thresholds are violated for specific metrics a notification and/or action is automatically triggered.
· Used Nessus Scanner to scan for any vulnerabilities.
· Provided vulnerability analysis, patch confirmation, configuration assessment, and sensitive data identification for EC2 environments and instances.
· Worked on VMware Care Systems Analytics for Epic for monitoring visibility into infrastructure and provider workflows; provided complete visibility into performance across all aspects of the EHR platform, workflows, and supporting infrastructure.
· Participated in agile process – planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iteration.
· Core member for conception, implementation of Business Intelligence initiatives.
· Prepared high-level business use case and developed it into multiple system use cases and Activity diagrams.
· Used UML to perform Use-Case analysis to capture the dynamic aspect of the application. Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams
· Developed UI document with UI designs and mock-ups through wireframes.
· Utilized Storyboards and screen mock-ups to obtain client feedback and approval.
· Worked in conjunction with the project manager, design team and developers to prepare project status reports and presented reports to clients in order to keep them current.
· Utilized prototypes and structured walkthroughs to ensure that all relevant requirements are properly addressed.
· Facilitated collection of Functional Requirements from system users, and prepared Business Requirement documents.
· Involved in the development of Business and Technical Requirements in preparation of Design and Functional Specifications for Business Needs and Processes.
· Worked closely with Business users to determine the workflow of the product.
· Performed walkthroughs of the prototype with end-users to better understand user needs.
· Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
Involved in the upgrading and enhancement of Capitol One's applications to grow credit and deposit portfolios, attracting new customers and improve cross-selling by streamlining the business processes, improving the customer facing mobile-based applications and enhance analytics platform to improve decisions, enhance marketing, and influence consumer behavior.
· Reported to the CFO our financial forecasts and annual budgeting process; developed, reported, and communicated KPIs to multiple functional groups and stakeholders, and analyzed various value drivers of the business to support overall growth initiatives and increased performance.
· Forecasted models for revenue changes and expenditure increases/decreases, and identified trend analysis to help management make strategic decisions within the business.
· Identified trading strategies/investment opportunities using FactSet. Assisted with correction of equity trade errors using FactSet.
· Collected, analyzed, and managed quantitative data and prepared meaningful financial reports to lead business improvement and 30% cost reductions.
· Developed and tracked key metrics including assessing revenue and profitability achievement against full year and monthly targets. Utilized Excel macros to automate recurring reporting tasks.
· Continually refined and evolved agile processes for predictable and rapid software delivery resulting in hitting 99% of project deadline.
· Managed the implementation of Capitol One SwiftID Identity Protection.
· Led all sprint planning, sprint reviews, sprint retrospectives, and daily scrums resulting in product features that reached 5 million users.
· Served as the main point of contact to drive effective communication throughout all project phases reducing costs through streamlined communication by $55,000.
· Conducted interviews and JAD sessions with the clients for understanding gathering, assimilation, organization, categorization, analysis, and documentation of business requirements.
· Coordinated architects, application SME, security, infrastructure, network, data integration, DBAs and operations team for creation of system requirements (functional and non-functional). Analyzed and mapped processes using VISIO (current state/future state) and communicated with various units to produce the use cases and its associated sequence and activity diagrams.
· Performed GAP analysis to identify system restrictions, potentials, and decommission activities.
· Created UML diagrams- Use Case Diagrams, Activity Diagrams, Sequence Diagrams and ER Diagrams in MS Visio.
· Assisted project and program managers in developing project Charter, Plans, estimation, and timelines.
· Analyze profitability for contractual milestones, tracking of over/under runs of projects, and prepare profit models.
· Supported the product owner in managing customer expectations for project deliverables and managed internal stakeholder communications resulting in 21% increase in customer engagement with new features.
· Performed wide array of estimates including Analogous, Parametric, Three point and Bottom-up estimates. Conducted business process analyses, needs assessments, and preliminary cost/benefits analyses in an effort to align information technology solutions with business initiatives.
· Developed and calculated Estimates-to-completion (ETC), Estimates-at-completion (EAC), and Burn rate analyses (CPI), SPI, SV, CV, VAC and TCPI.
· Prepared Functional Specification document that meets requirements and application behavior describing the detail design of the application.
· Identified and documented issues and risks, their descriptions, their impact and provided recommendations to develop the application to meet the user requirements.
· Managed the changes requested, its analysis and approval process with the Change Control Board (CCB) governance gate.
· Provided support by preparation of the traceability matrix, reviewing design deliverables to ensure alignment with client specifications.
· Generated Excel reports from SQL database and MS access database.
· Reviewed system test plans and system tests modules before implementation using SQL quires.
· Helped in Performing Data mapping, logical data modeling created class diagrams and Visio diagrams and used SQL queries to filter data.
· Execute the DB scripts provided by the developers, noted the resultant table data for further analysis.
· Built, developed dashboard reports using Tableau.
· Orchestrated several QA testing, User Acceptance Testing (UAT)/Beta Testing on all projects in coordination with client contacts for successful integration of company products before Go Live.
· Worked with the user to select or create appropriate scenarios to test all results to determine whether system changes met project specifications; used scenarios to assist the end user in acceptance testing.
· Created, reviewed and delivered end-user documentation (user guide, process flow charts, and training materials) and training for accuracy.
· Assisted Department Heads and managers with vendor selection process (i.e., contracts, financial reports, insurance certificates); completion of due diligence tasks and risk assessments for new vendors and critical vendors.
· Ensured enterprise-wide needs for due diligence, risk assessment and continuing vendor monitoring for third party service providers.
· Worked collaboratively with stakeholders to deconstruct vendor and compliance issues and develop a solution for risk mitigation.
The focus of the project was the replacement of 22-year-old Medicaid Management Information System (MMIS).
· Responsible for gap analysis in changing from a legacy MMIS to a new MMIS.
· Coordinated with the stakeholders and project key personnel to gather functional and non-functional requirements during JAD sessions.
· Worked with the customer to capture and translate high level functional, technical, and performance requirements into detailed acceptance criteria for epics / user stories in an Agile environment
· Studied the existing business process and created AS-IS workflow to illustrate the existing system.
· Recorded requirements in the Requirement Traceability Matrix (RTM) defining each technical requirement in detail from areas like: main hardware, application software, networks, servers, internet and desktop configuration.
· Configured and enhanced core application, including, but not limited to, Service Catalog, Service Portal, Incidents, Knowledge Base, Change Management, Project & Portfolio, and Reporting using ServiceNow.
· Performed Change Management, Defects, bug tracking, configuration management using ServiceNow.
· Experience and knowledgeable with AGILE Tool and Scaled Agile Framework environment (SAFe).
· Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
· Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
· Involved in HIPAA EDI transactions such as 270, 271,837 (P, D, I), 276, 277, 834, 811, 820, 278,999/TA1, and 277 CA.
· Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider. Utilized Molina's Healthcare Payer Administration Solution, Health PAS, that allowed Medicaid programs and State Children's Health Insurance Programs (SCHIP) to interface effectively and efficiently with new Health Insurance Exchanges.
· Worked into Healthcare claims process, EDI transactions, EMR (Electronic Medical Records), DSM (Direct Source Messaging) HIPAA (Health Insurance Portability Accountability Act), EOB, ANSI 837 UB92, 5010, HIX.
· Manage EDI for business partners' world-wide and was Responsible for new trading partner implementation including mapping and testing of various EDI transactions in ASCI-X12 and EDIFACT standards, to/from various internal processes and platforms.
· Identify opportunities for the creation of algorithms and data models to detect incorrect or fraudulent Medicaid billings.
· Involved with System Tester for Facets Billing and Finance.
· Defined Functional Test Cases, documented, Executed test script in Facets system.
· Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project.
· Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
· Developed Software Requirement Specification (SRS) document using Visio and MS Office.
· Responsible for creating business work flows and processes and creating management reports based on the analysis.
· Experience in Rational Rose & HP ALM/Quality Centre.
· Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
Responsible for designing future state processes for HIPAA 5010 transaction processing EDI's 837 and 835.
· Analyzed HIPAA X12 standard - version 5010 related to 837,835, 834.
· Performed Gap analysis between HIPAA 4010 and 5010; clear benefit with consistency of processing for payers and clearinghouse.
· Knowledge of ICD-9-CM and ICD -10-CM coding and claims processing.
· Involved in the creation and maintenance of the Workflow plans and artifacts.
· Organized system infrastructure documentation and operating procedures, strengthening controls and enhancing overall performance.
· Developed flowcharts and diagrams to describe and lay out logical operational steps.
· Prepared Business Process Models that include modeling of all the activities of the business from the conceptual to procedural level.
· Served as subject matter expert with respect to the annual benefit changes and rules associated with the Medicare Part D program.
· Documented Requirement Traceability Matrix (RTM) for requirement elicitation and linkup to deliverables.
· Worked with the individual sub-project managers to translate these into PRDs (Product Requirement Documents) for the development teams.
· Examined, analyzed and model Test plans, Use Case Model & Test procedures based on iterative development and round-trip engineering.
· Used Rational Rose to visually determine the proper structure, key elements and optimal design for Database and to aid efficient creation of tables, stored procedures.
· Executed SQL statements to extract data from different tables in database using joints, database links and helped formatting the results into reports.
· Evaluated the information gathered from multiple sources during requirement gathering and analysis and responsible for tracking, tracing and managing requirements using Rational RequisitePro.
· Followed the UML based methods using Rational Rose to create Use Cases, Activity Diagram, Sequence Diagram, Collaboration Diagram that include Functional and Non-Functional specifications to hand off to development teams.
· Performed Change Management, Defects and bug tracking using Rational ClearQuest; Configuration management and Version control with Rational ClearCase.
· Used MS Project for various planning and budgeting activities.
· Wrote clear, concise detailed System Requirements Specification (SRS) documents and user documentation in accordance to guidelines and standards of a level where developers can interpret, design and develop the application with minimum guidance.
Certified SAFe 5 Agilist (Present)
Certified Professional Scrum Master (PSM) (Present)
Certified AWS Cloud Practitioner (Present)
Certified in Lean Six Sigma (White Belt) (Present)
Spending time with my 2year old son
Passionate, relentless and obsessive to get the work done on time, under budget and with quality. Have adopted the true Mamba mentality.
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