Jeevan Pillai 5713140104 go2jgp@gmail.

com

SUMMARY:
 Systems Analyst/ Business Analyst withover 7+ years of experience in Healthcare Data Analytics and Business
Intelligence and Reporting Domain.
 Worked on Commercial, Medicare and Medicaid line of business and managing diverse team of technical experts in
analyzing systems, processes and improvements implementations.
 Created Technical documentation with Data transformation logics as per the business needs for Data extraction and
worked closely with external vendors, SFTP-ing Membership Data, Medical Claims & Encounter, Pharmacy Claims &
Encounter, Provider Data and Utilization Management Data extracts.
 Worked on BI reporting, Creating Report Books for ETL jobs from Teradata server to Hadoop then to Tableau reports,
and Business Object Reports
 Worked as Pega Analyst for Anthem EFUSE Team, an Application which will store historical and most updated Co-
Ordination of Benefit information among Anthem and Other Payers.
 Proficient in developing Business Requirement Documents (BRD) and Functional Requirement Documents (FRD),
Business Modeling Process (BMP) and Requirement Traceability Matrix (RTM).
 Sound experience Waterfall project models, Agile Project models, Waterfall-Agile hybrid Project Models, and Agile
Scrum Project models.
 Facilitating Stakeholder meeting for requirement gathering sessions, User Story Grooming sessions, Requirement
Walkthrough sessions with business, Technical Specifics Walkthrough sessions, Report Book Walkthrough sessions,
UAT walkthrough sessions for BO and Tableau reports.
 Experience with Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on important
dimensions of care and service.
 Knowledge of HIPAA Regulations and Claims & Encounter Processing with good knowledge of Health Insurance Plans
(Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare), billing experience with thorough
understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
 Created test plans, scenarios, test cases and test execution using ALM platform
 Successfully managed multiple projects concurrently.
TECHNICAL SKILLS:

Operating Systems: Microsoft Windows, UNIX

Languages: SQL, HTML, XML, X12 (EDI) and UML
Databases & Tools: SQL, Access, MYSQL, Oracle 9i/10g, Teradata – Teradata SQL Assistant, Hadoop
Quality Management: HEDIS, HP ALM-Quality Center, Rational Test Manager, QTP/UFT, Rally, MS Test Manager
(MTM), Team Foundation Server (TFS),
Business Modeling Tools: Rational Rose, Microsoft Visio, MS Excel, MS PowerPoint, Microsoft Visio
Change Management Tools: Rational Clear Quest, Requisite Pro
Reporting Tools: SAS, Tableau, BO
Project Management: Microsoft Project Professional, JIRA, Confluence
SDLC Methodologies: Agile, RUP, Waterfall, Spiral, Iterative
Others: MS (Visio, Outlook, Access, Word, Excel, PowerPoint) Share point, SnagIt 11 editor

WORK EXPERIENCE

Anthem Blue Cross Blue Shield, Richmond Virginia/Norfolk Virginia

System Analyst - Business Analyst October 2017 to Current

Project 1: Central Region Data warehouse/CRDW Decommissioning 2017: – IT Modernization, Data Orchestration and
User Migration
 Central Region Data Ware house is one of Anthem’s pioneer Data repository is getting decommissioned and soon
will be replaced by much larger and centralized Data warehouse called EDWard. When the data was migrated users
came across Data Gaps CRDW vs EDWard.
Jeevan Pillai 5713140104 go2jgp@gmail.com

 Pick up Data Issues identified by users of Edward (Enterprise Data warehouse), then root cause analysis of those
data gaps and write User stories and Technical responses to fix those gaps.
 If the Data gaps identified by users are due to code errors, user education sessions were conducted in order to
educate users.
Project 2: Commercial and Serviceability Business Division Partnership with Aspire (External Vendor) Data Extracts – All
Commercial Fully Insured
Membership Data, Medical Claims Data, Pharmacy Claims Data, AIM Clinical-Oncology Data, Census Data and
Discharge Data, which enables Aspire to evaluate the data provided and reach out to providers and members in order
to use terminally ill people to utilize the benefits and thus reduce cost to Anthem in long run.
 6 extracts created and send out to eternal vendor – Aspire who performs member outreach on behalf of Anthem.
 Created User story documents, Technical responses, UAT documentation, Provided complex transformation for
multi-system data pulls to integrate data as per the Business needs.
 Facilitated Stakeholder meeting for requirement gathering sessions, User Story Grooming sessions, Requirement
Walkthrough sessions with business, Technical Specifics Walkthrough sessions, UAT walkthrough sessions with
Business Product owners
Project 3: WGS South Carolina and West Virginia Medicaid Medical and Rx Claims & Encounter Encounter Extracts to
Aspire (External Vendor)
Data from WGS Claims & Encounter & Encounter Source System is utilized for data processing for South Carolina
Medicaid and West Virginia Medicaid in Data Exchange Team to send Medical Claims & Encounter and Pharmacy Claims
& Encounter, Membership, Utilization Management Data, Provider data to external Venders for their member outreach
programs.
WV Medical Claims & Encounter, WV Pharmacy Claims & Encounter, SC Medical Claims & Encounter, SC Pharmacy
Claims & Encounter
 Created User story documents, Technical responses, UAT documentation, Provided complex transformation for
multi-system data pulls to integrate data as per the Business needs.
 Facilitated Stakeholder meeting for requirement gathering sessions, User Story Grooming sessions, Requirement
Walkthrough sessions with business, Technical Specifics Walkthrough sessions, UAT walkthrough sessions with
Business Product owners

Project 4: WGS California Medicaid – Whole Person Care

Worked on generating and sending Data extracts to 4 counties in the state of California as a part of Anthem initiative of
California Palliative Care for the Whole Person Care and Health Homes for 4 counties
Alameda County
Membership, Medical Claims & Encounter, Pharmacy Claims & Encounter
Placer County
 Top 20 utilizers of Whole Person Care
 In-Patient Hospitalization Claims & Encounter
 Out Patient and Emergency Claims & Encounter
 Pharmacy Claims & Encounter
 Member list with PCP information extracts
Mariposa and San Benito Counties
 Membership
 Medical Claims & Encounter
 Pharmacy Claims & Encounter
Created User story documents, Technical responses, UAT documentation, Provided complex transformation for multi-
system data pulls to integrate data as per the Business needs.
Facilitated Stakeholder meeting for requirement gathering sessions, User Story Grooming sessions, Requirement
Walkthrough sessions with business, Technical Specifics Walkthrough sessions, UAT walkthrough sessions with Business
Product owners

Project 5: Utilization Management Flexibility and Green Pass Provider Program Reports
Provider Innovation Management Systems (PIMS) - Green Pass Program aka Prior-Auth Pass Program is an Anthem
initiative to privilege Providers who are in good standing with Anthem, can submit the Claims & Encounter with certain
Jeevan Pillai 5713140104 go2jgp@gmail.com

Procedure Code without having to have a Prior Authorization approval. The following reports has to created and delivered
to the business as part of this high visibility Project,
Worked on
 Medical Necessity reports (3 reports)
o Medical Necessity Provider report – Tableau and Business Objects
o Medical Necessity Reviewer (Nurse/MD) Report – Tableau and Business Objects
o Medical Necessity Summary report
 Hot Spotter Provider Report – Tableau and Business Objects
 Hot Spotter Procedure Code Report - Tableau and Business Objects
 Claims & Encounter Utilization Report – Business Objects
 Claims & Encounter Audit Reports – Tableau
 On – Boarding Providers Claims & Encounter Utilization Report (3 reports)
o Detail Report – Business Objects
o Summary Reports - Tableau
o Provider facing Code list reports -
 Provider – Procedure Code Threshold Report
Created Separate User story documents and Report Books for above reports and performed Business and Technical
walkthrough, closed defects identified by testers by providing appropriate transformation logic to fit business need,
Conducted UAT walkthrough sessions of the above reports with the Business stakeholder to get the acceptance approvals.
Project 6: CALPERS - California Public Employees Retirement System Medical and Rx Claims & Encounter extracts to
Optum (External Vendor)
 Medical Claims & Encounter
 Pharmacy Claims & Encounter
Created User story documents, Technical responses, UAT documentation, Provided complex transformation for multi-
system data pulls to integrate data as per the Business needs.
Facilitated Stakeholder meeting for requirement gathering sessions, User Story Grooming sessions, Requirement
Walkthrough sessions with business, Technical Specifics Walkthrough sessions, UAT walkthrough sessions with Business
Product owners
Project 7 - E-FUSE: (Pega Application) This project is based on Co-ordination of Care of Anthem, health insurance
members.
Project 8 - Claims Intake and Workflow (Pega Application) – This is mainframe to web based application migration of
workflow.

CVS Caremark – Omnicare Pharmacy, Solon, Ohio

Business Analyst Consultant March 2017 to September 2017
CVS Caremark Pharmacy has acquired Omnicare Pharmacy 2 years ago. CVS Pharmacy services individual patients but
Omnicare Pharmacy only services to Long Time Care (LTC), Assisted Living Facility (ALF), Skilled Nursing Facility
(SNF), Prison Rehabilitation centers and similar facilities. Name of the Project was “Improve Customer Service”. Currently
the Omnicare Pharmacy dispensing systems don’t have a standardized capability to communicate with the facilities in order
to get missing information so that the users can proceed with the Order Entry. Each pharmacy follows their own procedure
to contact with the Facilities. BA team was responsible for gathering requirements for the Customer Service Queue both
Action Queue and Pending Queue, outbound fax templates, merging incoming document/prescription with the outgoing
Fax document, Generate prescription incase for pending refills, Configuring Client preferences, Linking Outbound request
with the pending Order entry, configuring the frequency of communication in case of failed attempts, Generate and Print
Delivery Manifest.
Responsibilities:
 Capturing requirements and defining Customer Service Action Queue and Pending Queue, its access, display,
attributes and navigation.
 Written logic for Client Preferences and Cadence (Frequency to communicate with the facility or prescriber),
number retries and time gap between each attempts.
 Created Work flows using MS Visio to indicate how automatically and manually link an incoming document with
the Order document.
Jeevan Pillai 5713140104 go2jgp@gmail.com

 Created mockups with Snagit 11 editor to simulate the displays of the Queues, Outbound Communication Request
detail screen, and Simulate Delivery Manifest print preview.
 Extensively user MS Excel to create numerous Matrixes to map Client preferences and Cadence Logic.
 Contributed to Business Requirement Document for Improve Customer Service Project.
 Played pivotal role by contributing with functional Requirements and Use Cases and drafting the Solution
Requirement Package (Functional Requirement Document) to fulfill needs of the Business.
 Facilitated Daily status meetings, Requirement Gathering meetings and follow up meeting with the Business
to close out all the action items in a timely manner.
 Presented MS PowerPoint slides to the Business to clarify the requirements whenever needed.
 Worked closely with Solution Architect to understand the technological limitations and refined the requirements
taking account of IT team’s inputs.
Environment: UNIX, Windows, .Net, SQL Server Management Studio, , MS Excel, MS Word, MS Visio, MS SQL, MS
Power Point.

United Healthcare, Remote/Plymouth, Minnesota Server

Aug 2016 to March 2017
Systems Analyst / Business Analyst
HEDIS Key Performance Indicators Program (KPI) in Population Health Management of United Healthcare. United
Healthcare’s 2016 Business Objective is to improve Population Health Quality by increasing number of members in 4 star
plans or higher. The purpose of the project was to design, and develop a system, tools and Processes which will be utilized
to monitor HEDIS inputs (Data) and outputs (Measure rates).HEDIS Breast Cancer Screening – The objective was to
conduct a pilot study for the upcoming 81 measures. Breast Cancer Screening was selected for the Pilot. The methodology
of the project was Agile.
My role in HEDIS team was Gathering and documentation of requirements as per NCQA Specs, work closely with
Programmers to access and confirm specific the specific fields in DB2 Galaxy Data warehouse using SAS/SQL queries,
Verify Codes, Validates and test the program written for Denominator and Numerator data for Breasts Cancer Screening
measure, Create Ad-hoc and Static report for the leadership and to find out the Procedure code and Diagnosis Code changes
year over year by creating lookups in excel work sheets.

Responsibilities:
 Capture and document the business requirement, then present to the BSA/BA team and then give presentations in the
Weekly team meeting to update the status of work.
 Created System Specification document to locate and specify the data from sources like DB2 Galaxy Data warehouse,
specify the actual tables and columns from Facets Claims & Encounter data need to be pulled in order for the
programmers to Code for Denominator and Numerator Data.
 Created Programing ER diagram for BCS, FPC Measures.
 Created test data for 837I, 837D, 837P to have Segments/loops information with different combination of Submitter,
Receiver, Billing Provider, Pay-To-Provider, Subscriber, Payer, Patient, Claim Information, Physicians, Referring
Provider, Service Line Info, Adjudication Information
 Lead the project as HEDIS Subject Matter Expert (SME) and liaised between client and payer/intermediary.
 Worked closely with Programmers to Verify SAS Codes for the Facets Claims & Encounter Data pull for Denominator-
Numerator Values.
 Reporting Data bases like H-Pro and C-Mart and Claims & Encounter Data ware houses like DB2 Galaxy contains
periodically loaded Claims & Encounter data from the Facets Claims & Encounter adjudication tool
 Responded to billing inquiries from patients and payers.
 Created Crosswalk on Medical/Pharmacy/Revenue Code Changes from 2016 to 2017 HEDIS specification.
 Written Proc Freq., Proc content, Proc SQL statements for the Validation and Verification of thee Facets Claims &
Encounter data.
Environment: UNIX, Windows, DB2, SQL Server Management Studio, SAS enterprise Guide, MS excel, MS Word, MS
Visio, MS SQL, MS Power Point, Tableau, Facets.
Jeevan Pillai 5713140104 go2jgp@gmail.com

Anthem Blue Cross Blue Shield, Cleveland, OH Jan’2015 to Aug’2016

Systems Analyst / Business Analyst
Blue Cross Blue Shield is one of the leading Healthcare Provider in the United States. With the objective of increasing its
sales and image in Florida, the company wanted to improve their website to provide online sales support and assistance to
the consumers in choosing the products, by cutting down the role of C.P.U (an agent). I was responsible to create benefit
cost reports for BCBS Plan by using DM (Disease Management) Scorecard report and HEDIS report.
I was involved in the multiple projects such as HEDIS Reporting system, Disease Management, CCP (Care Coordination
Portal).

HEDIS Release 3.3

The objective of the Healthcare Effectiveness Data information Set (HEDIS) release 3.3 is to build upon previous release
of HEDIS application- adding new columns, modifying existing columns, and adding new filters, creating a scaled version
of HEDIS Report, Removing certain domain from the HEDIS Report, updating the HEDIS supplement files and process of
the Supplement data file and Crating User interface to update measures and sub measures

Responsibilities:
 Extensively interacted with the stakeholders, SMEs and the IT Department in finalizing the requirements according to
the CMS Compliances/Regulations and HIPAA Regulations.
 Successfully created a Business Requirement Document (BRD) and Functional Requirement Specifications (FRD) in a
timely manner
 Conducted the FRD reviews and walkthroughs with designers, developers and stakeholders.
 Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams/State
Chart Diagrams (UML).
 Successfully analyzed X12 (EDI 834, 835, 837, 270, 271, 276, 277) files from Facets system and XML codes.
 Successfully worked with Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on
important dimensions of care and service.
 Created Data Stage jobs to extract, transform and load (ETL) Facets Claims & Encounter data into data warehouses
from various sources like relational databases, application systems, temp tables, flat files etc.
 Created Process Flow diagrams, Use case diagrams (UML) using MS-Visio
 Prepared Screenshots, Mockups and web layouts for the application
 Prepared Test Strategy, Test Plan, test report and Gap Report
 Performed UAT based on Requirements Document and prepared the Test Cases using Quality Center.
Environment: HEDIS, HP ALM-Quality Center, Facets, MS Project, MS excel, MS Word, MS Visio, MS SQL, Agile, MS
Power Point.

Metro Health, Wyoming, MI Sept’2013 –

Nov’2014
Systems Analyst / Business Analyst
Metro Health is one of the leading healthcare providers in Michigan. The Metro Health system includes Metro Health
Hospital, a 208-bed general acute-care osteopathic teaching hospital in Wyoming, Michigan, and physician offices located
throughout greater Grand Rapids.
I was involved as a SA to enhance their ERP based resource management web payment portal which helps their customer
to make their payment easier and faster. For this system the customer needs to enroll through the Metro Health's online
Patient e-Services.
Responsibilities:
 Successfully developed Business Requirement Documents (BRD) and Functional Requirement Documents (FRD)
 Conducted and participated in JAD Sessions periodically with various Subject Matter Experts at various phases of the
Software Development Life Cycle to discuss open issues and resolve them.
 Made a Gap Analysis and assisted the development team to understand the To-Be process.
 Created documents like the Business Glossary to facilitate the other teams in understanding client business.
 Prepare required regulatory reports which show the progress on the collection reporting and analysis of the HEDIS.
Jeevan Pillai 5713140104 go2jgp@gmail.com

 Successfully worked with Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on
important dimensions of care and service.
 Review detailed Claims & Encounter data in order to verify HEDIS rates as necessary.
Environment: HEDIS, Agile, Rational Requisite Pro, Rational Rose, Rational Clear Quest, QNXT, RUP, UML, MS-
Project, MS Office, UNIX, MS SQL Server.

Medical Center of Dallas Oct’2012 – Aug’2013

Business Analyst/Systems Analyst
User Interfaced Web application, which enables customers to view and manage account information, pays bills and make
appointment with doctors online. It also enables the authorized employees to see customer account information, status and
make necessary modifications. This application helps collection agency to track the patients who are not up to date with
their account and insurance agency to get bill electronically.

Responsibilities:
 Gathered Business Requirement through interviews with SMEs (subject matter expert) like medical transcripts,
collection agency, insurance agency and typical patients, etc and captured requirement using Rational Requisite Pro.
 Worked on Enterprise Resource Management (ERP) systems to configure in order to integrate various enterprise Data
repositories.
 Followed the UML based methods to create Use case Activity Diagrams/ State Chart Diagrams, Sequence Diagrams,
Collaboration Diagrams
 Responsible for the definition and the scope of the business requirements for the application developed
 Responsible for the documentation of the various modules that were involved in the business process
 Gathering of business requirement and converting them into Functional Requirement Specification and User
Requirement Specification
 Interacted with the Business Users to convert requirements document into Business System Design documents and
Technical Specification for the Development Team
 Involved in creating queries, stored procedures and views in SQL
 Conducted regular ERP System Specs walk-through with the developers and testers.
Environment: Agile, Rational Requisite Pro, Rational Rose, Rational Clear Quest, RUP, UML, MS-Project, MS Office,
UNIX, MS SQL server.
Kaiser Permanente, Thousand Oaks, CA Jan’2011-Aug’2012
Business Analyst/Systems Analyst
Kaiser Permanente is one of the nation's largest publicly traded health benefits companies, with approximately 9 million
medical members. The system initiates all the necessary procedures, standardizes and validates the data according to HIPAA
regulations, and provides error-processing for the transactions that could not be fully processed through the system. The
new application also allows the agents to track and manage the status of a health benefit Claims & Encounter.
Responsibilities:
 Reviewed EDI 837 Claims & Encounter and flagged HIPPA noncompliant Claims & Encounter received from the Payer
side.
 Performed manual back-end testing using PL/SQL to connect to an Oracle 9i database on a UNIX server
 Successfully worked with Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on
important dimensions of care and service.
 Tracked and reported defects using Quality Center.
 Performed some backend testing using Database Checkpoints in QTP
 Investigating software bugs and reporting to the developers using Quality Center Defect Module
Environment: HEDIS, Soap UI, HP/ALM- Quality Center, HIPAA, EDI 5010, FACETS, QTP, Windows, SQL Server.

EDUCTATION:

Masters in Computer Information System, from American College of Commerce and Technology, USA
Masters from Rajiv Gandhi University of Health Sciences, Bangalore, India
Bachelors from Mangalore University, Mangalore India