kamaldeep singh

kamal.singhlead12@gmail.com

Over 7 years of professional experience as Business/System Analyst with expertise in Software Development Life Cycle
(SDLC) in Health Care Sector with prime focus on EMR, HL7, claims adjudication, provider, eligibility and prior
authorization for Medicaid and Medicare programs.
 Extensive experience in training corporate and independent clients on subjects like Business Analysis, Business
Process Modelling and other core areas of Business Analysis like, Enterprise Analysis, Effective Requirement
Gathering, Skills to survive as a BA(for clients on job) and SOA(Service Oriented Architecture). Also worked on legacy
modernization methodology including the tasks, models and techniques.
 Experience with health care Systems: FACETS
 Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication)
 Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS.
 Having excellent knowledge and worked as a SME on Medicare, Medicaid, Medicare Advantage, MediGap, HIPAA
Standards (HL7), EDI Transactions (4010), ICD-9 and ICD-10 Codes, and FACETS Healthcare Platform. Also, used Clarity
PPM (Project Portfolio Management) to provide industry best practices for utilizing the Clarity product.
 Highly analytical in developing the methods and measures to meet requirements and solve any issues that arise
during the project.
 Proficient in the use of tools like Telelogic DOORS, Rational Rose, Requisite Pro, Rational ClearCase, Telelogic System
Architect and MS Visio.
 Well experienced in CMMi, SDLC, and Agile development methodologies. Healthcare domain and experience in areas
of Healthcare EDI transaction sets (834,835,837i/p, 820, 997/999), HIPPA, ACA and Health Insurance Exchange.
 solution to the customers for Facets Production Issues.
 Supported new business requirements by extending the functionality of the core Facets system using the Facets
extensibility architecture feature.
 Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL
Enterprise Manager, Data analysis and reporting.
 Working experience in a cross-functional team environment/different geographical locations teams.
 Experience with data analysis, data mapping and dimensional modeling experience in decision support systems (data
marts) using Star Schema.
 Experience in requirements gathering for development of the customer MDM data models.
 Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation,
providers).
 Experience with HIPAA compliance (4010 & 5010) and Healthcare systems
 Experience with Medicare, Medicaid, Medigap/Medsupp & commercial insurances in HIPAA ANSI X12 4010, 5010
formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats
for interfaces & images to clearinghouses/ trading partners applications.
 Experience with health care Systems: FACETS, Medicare Part A, B, C, D, Medicaid systems.
 Experience in developing and imparting pre and post implementation training, conducting GAP Analysis, User
Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis.
 Driven by creative ideas and backed by strong Analytical and methodical problem solving skills, identifying causes,
corrective actions and providing innovative solutions, building strategic partnerships with senior business leaders
and getting commitments to actions from individuals at all levels.
 Extensive experience on Excel, Word, PowerPoint, MS Project, MS Visio, Rational Suite and SQL.
 Highly motivated self-starter with excellent communication, presentation and interpersonal skills, can perform well
both independently and with a team, always willing to work in challenging and cross-platform environments.

TECHNICAL SKILLS:

Business Tools Retalix, Proxis Store Manager Classic, TeleTracker Business Suite, PRAPP
Microsoft Tools MS Project, MS Visio, MS Office, MS Outlook, MS FrontPage
Databases & Languages Oracle, MS Access, .NET, MySQL, SQL, HTML, MS Visio, Rational Suite (Rose, RequisitePro,
RequisiteWeb,ClearCase, ClearQuest) Java, Doors, XML
Testing Tools HP Quality Center, Mercury Test Director, WinRunner, Load Runner, Rational Robot,
Quick Test Professional
 Methodologies & Standards RUP, Six Sigma, SDLC Agile, QA, HIPAA, Medicare Software, ezclaim, Medicaid, SOA,
CMM, CMMI, PMBOK
Operating System Windows 95/98/NT/2000/XP, UNIX, Linux
Tools Adobe Acrobat, Business Explorer, Toad, Data Warehousing, Lotus Notes
Skills Rational Rose, Rational Requisite Pro, Rational Clear Quest, Snagit, Rational Unified
Process, UML, SOA, Business Process Modeling, MS Visio, MS Word, MS Excel,
PowerPoint, MS Project, MS Access, MS Outlook, ERWin 4.5, SharePoint, Cognos, Crystal
Reports Visual Basic 6.0, Java, Object Oriented Programming, C++ .Net, UNIX, Windows
NT/ 2000/ XP, MS SQL Server, BlueChip, FEP Express, VDR Data System, BlueSource,
Coordinator Mouse.

Professional Experience:

Affinity Health Plan, NYC, NY May 2016 – Till Date

Sr. Systems Facets Analyst

Affinity Health Plan is an independent, non-profit managed care plan that serves the needs of over 210,000 underserved
residents of the New York Metropolitan Area (New York City, Long Island, Westchester, Rockland and Orange Counties.)
Affinity provides healthcare coverage through its Child Health Plus, Family Health Plus and Medicaid programs. Affinity
Health Plan implemented Facets Extended Enterprise(TM) administrative system, a new core system, with updated
technology to allow for more efficient claims processing, membership enrollment and provider data maintenance. Facets
was highly efficient, automated, customizable, and flexible, to help affinity tackle new business opportunities and
compete successfully in a dynamic healthcare industry. Moreover, TriZetto provided ongoing support and training.

Role & Achievements:

 Assisted in the Project manager in creating and updating the Vision Document, Business case, and the Project Plan
to define Objective, Scope and Risks. Also assisted in creating RUP iteration plans and phase plans
 Elicited requirements, and managed Change Configuration to maintain an orderly procedure for managing
requirement changes after sign off
 Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
 Followed AGILE methodology viz. Scrum throughout the project.
 Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health
Insurance.
 Experience with BlueCross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12, 4010 and 5010 ICD9
and ICD-10 implementation guidelines & electronic formats including 270/271, 276/277, 700, 701, 810, 820, 834,
835, 837, 997, and NSF formats for interfaces and images to third part vendor applications including NEIC, SSI, ESI,
Datatrac, Medtrac, Cube, BlueCross, Medicare, and several others using COBOL, Metafile, Visual Basic, Unix, DOS,
Assembler, C, FTP, Windows, Novell, and various other communication packages.
 Created Heat map with alert mechanism. Various KPI graphs were drawn. Kept eye on Qlikview best practice
 Project entailed developing a data model based on MS SQL Server and Tableau Server.
 Worked as Subject Matter Expert (SME) for various projects. Taught the users to get along with Qlikview.
 Elicited functional specifications, conducted feasibility analysis, and performed impact analysis
 Elicited Business Rules and other Non-functional specifications for the new system by interviewing the Subject Matter
Experts (Doctors & Nurses) to further understand the business models
 Authored functional specifications for different HL7 system interfaces: ADT (registration), SIU (scheduling), OMG (rad
order entry), and ORP/RDS (Rx processing)
 Designed, developed, and implemented innovative & sustainable Tableau reports. Supported effective rollout of
reports, including training collateral
 Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing,
Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary
format files and Reports development.
 Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997
 Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit
medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276
(claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
 Responsible for Back-End Testing Using SQL Commands using TOAD.
 Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response &
820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
 Responsible for positioning and delivering QlikView projects and cross building applications into new and existing
customer base
 Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally
developed extensions and third party software for pricing and contract configuration.
 Gathered requirements from the clients and developed crosswalks for 277/288, 834, 835, 837 P/I claims
 Created Request For Proposal to identify possible vendors and obtained cost and functionality information
 Created UML Activity Diagrams to depict business processes (AS-IS and TO-BE) and analyzed them for their efficiency
and productivity.
 Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time
transactions like 270/271/276/277 for Medicare and Medicaid programs in FACETS.
 Tracked UAT issues/bugs and prepared reports.
 Developed test cases based on the crosswalks and compliance guidelines for 277/288, 834, 835, 837 Professional,
Institutional and Dental claims and for 270/271 eligibility benefit inquiry and response
 Created Use Case Model using Rational Rose for developers and other stakeholders to understand the business
process, depict roles, and procedures
 Daily management activities included educating portfolio managers, financial analysts and risk managers on the cost
of third-party financial research using business intelligence dashboards from Tableau Software.
 Decreased customer complaints and dramatically reduced post-implementation support. Involved in forming
strategy for increasing call conversions.
 Worked on customizing the claim module of FACETS for reprising Nursing home claims.
 Reviewed analysis of call center’s achievements of key client goals, ensuring continuous and consistent performance
 Data mapping on Enrollment Module (EDI 834) of FACETS.
 Experience in integrating claims, eligibility, provider and data information using facets.
 Facilitated requirement-eliciting sessions (JAD sessions) with Subject Matter Experts and other Key Users and
documented the requirements in an easy to understand format by both the business and technical personnel
 Constructed Use Cases and Wireframes and translated them into a Functional Requirement Specifications document
 Expertise in iterative approach of AGILE development with all the teams members
 Involved in all phases of Software development life cycle (SDLC) using Agile Scrum methodology.
 Establish documentation for agile methodology for implementation with a very water-fall-centric development team.
 Performed manual testing, including validation/smoke testing of HL7 interface messages on each new build before
delivering to quality assurance team
 Coordinated daily activities with the IT Developers, QA and Product teams along with the project management group.
 Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA
guidelines, and coordinated user acceptance testing using derived test data
 Generated test data using X12 generator for transactions 277/288, 834, 835, 837P/I/D. Conducted Gap Researched
and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
 Created Online User Guide comprising different scenarios, screenshots, and troubleshooting procedures

Environment: MS Project, MS Excel, MS Word, Rational Rose, Agile, MS PowerPoint, Facets, Tableau, UAT, Oracle 9i,
QlikView , Citrix (server), Epic

Horizon BlueCross BlueShield of NJ Sep 2014- Apr 2016

System Facets Analyst

Horizon BlueCross BlueShield of New Jersey (Horizon BCBSNJ) is the state's largest health insurer providing individuals
and employers in New Jersey with quality health care. The project required an in depth process review to support the
migration of the Mainframe based system to a browser based platform.

Role & Achievements:

 Developed the High Level Project Requirements (HLR) for a very large project.
 Modified and used Project Templates to gather the requirements and carry on the project. Also worked on legacy
transformation methodology including the tasks, models and techniques.
 Worked on FACETS for healthcare plan administration. Also, experienced on claims adjudication to provide the best
claims management service.
 Worked as a SME on Medicare, Medicare Advantage, MediGap, HIPAA, HL7, EDI Transactions and all other
compliances.
 Coordinated the project team for JAD and BRD Sessions.
 Followed a structured approach to organize requirements into logical groupings of essential business processes,
business rules, information needs and insured that critical requirements are not missed
 Worked on FACETS for healthcare plan administration. Also, experienced on claims adjudication to provide the best
claims management service.
 Followed solely RUP methodologies during the course of the project.
 Coordinated activities between business unit and technical staff, developed new methods, policies, and procedures
to meet the business needs.
 Developed EDI application interfaces for Shipment Order Requests (850, 940, 856s) with Expeditors for Goldbug’s
warehouses.
 Created and corrected EDI 850, 856 & 810 maps using Gentran:Server for Windows/Application Integration software
interfacing data to/from JDEdwards ERP package.
 Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.
 Performed Requirement Analysis by gathering functional requirements and represented them in Requirements
Traceability Matrix (RTM) using RequisitePro.
 Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing,
Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary
format files and Reports development.
 Participated in Facets Table data modeling, planning, designing, implementing the data warehouse and conducted
testing by developing complex SQL queries.
 Prepared Functional Design Specifications (FRS) employing Use case scenarios, sequence diagrams, DFDs and class
diagrams.
 Defined maps to customized claims daily load into Facets for processing the transactions.
 Identified and clearly defined functional issues and supported IT development staff throughout the design,
development, unit testing, and implementation phases of the software development life cycle.
 Documented and assisted the QA Team with the Test Plan.
 Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
 Developed Data Conversion Strategy using ETL functions for converting data from the existing site to the new site.
 Assisted Project Manager to complete the project approval process.
 Developed the prototype for PDA application “Rehab without walls” for interfacing with billing and invoice
application
 Migrated EDI traffic (X12 docs 850, 856, 810, 830 & EDIFACT messages DESADV, DELFOR, DELJIT) of Henkel Loctite
Canada & Henkel Surface Technologies Canada from their legacy applications to the new SAP ERP system.
 Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
 Worked on ‘FACETS Healthcare Solution’ to make the organization efficient in responding quickly and effectively to
the change around the healthcare market.
 Developed Templates to gather the requirements for applications to be added in SATS
 Followed a structured approach to organize requirements into logical groupings of essential business processes,
business rules, information needs and insured that critical requirements are not missed
 Involved in planning, execution, coordination of entire testing (QA) life cycle
 Developed strategies for Test Planning, Test Case Designing, Test Scheduling, Test Estimation, Test Execution and
Defect Tracking
 Assisted the QA team in SIT and Business in UAT

Environment: HTML, XML, MS-Project, load runner ,Agile method ,Sharepoint, Contact center, Facets, MS-Office Suite,
Rational Suite, Doors, RequisitePro, RequisiteWeb, UML, IBM WebSphere, Microsoft Visio, SQL/PLSQL,SQL Server 2005,
Rational tools

Celtic Healthcare, Inc. Pennsylvania, PA Apr 2012- Aug 2014

Business System Analyst

Celtic Healthcare, Inc. Pennsylvania, PA .its health plans with consumers across the US. A leading health insurer, it offers
a variety of plans and services to group and individual customers nationwide. Requirements are gathered as per the client
need and configured in FACETS The configuration task includes adding new markets for Community & State Platform. I
am currently working on analysis and Configuration part in Medical Agreement Configurator, Fee Schedule, and NetworX
Qualifier Group.

Role & Achievements:

 Led a team of business analysts both onsite and offshore within the Correspondence Report Competency Center at
Medica for the Phoenix program.
 Gathered requirements for correspondence and report generation from functional and business owners and
converted these requirements into User Stories.
 Participated in all Iteration, Scrum, Daily stand-ups and Iteration review meetings working in an agile development
methodology.
 Led Sprint Planning meetings, getting estimates from individuals (BA’s) and assigning tasks based on
velocity/capacity.
 Coordinated the upgrade of EDI Transaction Sets 837, 835 and 834 to HIPAA compliance. Work on EDI 834-file load
in Facets through MMS (Membership maintenance sub-system).
 Closely worked with all BA’s and stake holders for reviewing User Stories and scoping documents.
 Gathered requirements from carriers, interpreted XML documents and created mapping documents.
 Coordinated with Minnesota Health Exchange (HIX) program staff and other stakeholders to define and develop
requirements for correspondence generation across various business lines.
 Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
 Analysis and Design of the FACETS data model to ensure optimal system performance and tuning
 Configured facets modules such as Claims, Membership, Billing, Benefit and plan
 Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed
(837P, 835, 834)
 Practiced agile methodology, led sprints and prioritized line items based on key business initiatives with respect to
the ACA mandate and Health Care Reform Act
 Led JAD sessions with subject matter experts (SMEs) from each work stream/business unit for particular
correspondence lifecycles, process flows, and triggering conditions etc. for development within the HP Exstream
environment; translate business requirements into a functional document and solution design.
 Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared
Business Requirement Documents (BRD) using Rational RequisitePro.
 Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
 Standardized and validated data tags, created data dictionaries for new and existing correspondences and reports
for the purposes of data analysis.
 Worked closely with HP Exstream and Health Rules developers to understand system specifications.
 Helped develop integration solutions that create interoperability between Health Rules and HP Exstream.
 Tracked user stories, tasks, burn down hours and project progress in Version 1 efforts across various work streams,
participate in daily scrum meetings, provided status reports, impediments and milestones to scrum masters to meet
tight project deadlines.
 Raised issues and escalations in IRAAD as possible threats to project deadlines.
 Led Member Experience Review Boards to gather a user experience perspective on content, usability and readability
of correspondences. Liaison closely with content writers to align the content to specific and unique business needs.
 Involved in claim adjudication process of facets application
 Devised workarounds and made recommendations to solve intricate problems eg. system capacity and limitations,
operating time.
 Worked with Quality Assurance team to validate system acceptance and user acceptance test plan (UAT) and test
scripts.

Environment: Rational Suite (Rose, RequisitePro, RequisiteWeb), Rational Unified Process (RUP), Informatica, facets,
Windows XP/2000, Doors, Oracle, IBM WebSphere, SQL, System Architect, MS-Project, MS-Office Suite, MS Visio, MS
Word, MS Excel

PSA Healthcare, Aurora, Colorado Jun 2010- Mar 2012

Business Analyst

Worked on developing ecommerce Integrated Marketing Platform (IMP) portal intended to increase the marketing return
on investment (MROI) and increase conversion rates. The system was integrated with healthcare and pharmaceutical
systems to track the marketing efforts. The application interconnected with EMR (Electronic Medical Record), Patient
Billing, EHR (Electronic Health Records) Business Intelligence and Integration Solutions to streamline business processes
and improve responsiveness in critical business areas.

Role & Achievements:

 Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy
Management Systems, Payables/Receivables and Claims processing.
 Met with individual departments to communicate SharePoint purpose, application and vision for the future
 Experience with HIPAA Act Rules and regulations & HIPAA transactions
 Created different users, roles, Document libraries, Form Libraries, Team sites for projects, Issue Lists on SharePoint
Server 2003
 Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance),
270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
 Understood the relationship of various FACETS table involved in the project.
 Analyzed and validated results of various FACETS tables involved in the batch process using SQL and PL SQL in Oracle
SQL Developer and TOAD.
 Completed the documentation of Claims Scenario’s for the source system
 Developed data cleansing and data auditing procedures to clean external data and provide audit logs of rejected
data.
 Generated EDI specifications using EDIFECS SpecBuilder for all the transaction sets exchanged with Mervyns.
 Designed and developed Use Cases using UML and Business Process Modelling.
 Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence
Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using
Microsoft Visio.
 Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life
cycle.
 Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are
executed during testing process.
 Documented entire EDI Infrastructure and all of the EDI processes
 Designed conceptual and logical data models of Data Warehouse and tables.
 Using Shared Containers and creating reusable components for local and shared use in the ETL process.
 Verified the Business Scenarios on new builds to allow extended testing by the QA team.

Environment: .NET, Oracle 10g, Facets , MS Office Tools, IBM WebSphere, MS Visio, Lotus Note, Outlook, Share Point,
Citrix, TOAD.