Candidates About

                                          

Rajini Sivalingam

SUMMARY

·         More than 14 years of experience in information technology as a Senior Business/System Analyst/SME Lead with experience in business/system analysis, design and development of applications, testing, group enrollment/Billing and configurations with FACETS and PEGA 7.x.

·         9 Years of BCBSIL (HCSC) & BCBSMD (CareFirst) Experience as Facets 5.1/PEGA 7.x expert in claims processing, enrollment, Billing/Finance, membership, Benefits Management and billing/payments and I have also performed well in testing lead/manager/business architect roles on healthcare migration or reform projects with Pega/Tibco/Facets/Members Edge/NetworX

·         Specific industry experience, health care, retail, Bank & financial services.

·         Worked with all facets of the software development life cycle including design, analysis, and development and testing of web-based and n-tier client/server applications.

·         Comfortable with internet technologies such as HTML, DHTML, CSS, XML, XSL, XSLT and JavaScript and Comfortable working with Mainframe/NASCO COBOL, JCL, CICS and DB2

·         Extract, Transform and Load (ETL) and BI tools have been used in the projects on loading the data and maintain the data for reporting with Cognos and Star Schema to maintain data

·         Familiar with relational database design and other database management oriented concepts such as writing stored procedures, PL/SQL, database triggers, views and RFP Development.

·         Used case tools such as rational rose and ITIL to maintain process.

·         Translated business requirements into UML diagrams/Visio Diagrams and detailed designs.

·         Highly self-motivated with excellent analytical and problem solving skills.

·         Extensive knowledge on workflow analysis with the help of UML,BPMN and Use Case diagrams, Data Flow Diagrams, Component Diagrams, Sequence Diagrams and Activity Diagrams and ability to translate them to System Requirement Specifications, Technical Specification.

·         Thorough knowledge of industry standard SDLC practices such as Agile, SCRUM, Rational Unified Process (RUP), Rapid Application Development (RAD), Joint Application Development (JAD), and Waterfall; and various SDLC phases including Requirements, Analysis, Design, Development, Testing and Implementation of software applications

 

EDUCATION

·         Bachelor of Engineering, Electronics & Communication, Institute of Road and Transport Technology, Barathiyaar University, Coimbatore, India

CERTIFICATION & ACHIEVEMENTS

·         Certified Business Analyst

·         PMP from PMI

·         Accenture Trained Agile-Scrum candidate and Best Tester & Testing team awards from ATS Inc.

·         HC 101, Claims 201 & AHM

·         Pega certified professional

 

SKILLS

Operating Systems                    Windows (all), HP-UNIX, Linux, MVS/ESA, OS/390, IBM 3270 TSO

Programming Languages          Java, COBOL, C, C++, VB, Agile, Scrum

Mainframes                               JCL, CICS, VSAM, IMS-DC, Clear Quest,

Unit Testing                               JUnit

RDBMS                                     SQL Server 2005, ORACLE 11i, My SQL, DB2, APD, DD and OAAPI

Healthcare Tools                        FACETS 5.0, Hiperstation, EDIFECS 7.0 & 8.3, NASCO-NPS

Automation testing tools            Mercury QTP, Load runner, Win runner, Members Edge, PEGA 7.x

                                                   Rational Robot, HP Test director, Quality Center, Clear Quest, BPMN

Business Analysis Tools            Relativity Application Analyzer, Profiler, Clarity, MS Visio, RUP, RFP

                                                   Business Rule Manager, Req Pro/Web, Visual Studio 2010, UML, HPXR

Special Software                        MS Visio, MS Excel, MS Word, MS PowerPoint, ETL, Cognos, CISCO

                                                   MS Access, MS Share point, Lotus Notes–Citrix client, SharePoint 2010

Methodologies                           Agile, Scrum, V-Model and Waterfall Model, ITIL, NetworX Pricing

Knowledge on                            HIPAA- EDI transactions of 270/271, 834, 820, 276/277, Grasshopper

                                                   275, 835, 278, 837 I/P/D, Medicaid/MMIS, ACT/Obama Care, EPICS 

                                                   HIPAA ANSI X12 4010/5010, ICD 9 to10, PBM, 340B or PHI and SPI

EXPERIENCE

Oct’14 – Feb’17          PEGA Senior Business/System Analyst, Care first BCBS, Owings Mills, MD

Broker Express –Enrollment, Billing/Finance & Group Configuration/Implementation Automation with FACETS and PEGA 7.x-Business/Testing

Care first has the group enrollment, Billing/Finance PEGA based Broker express system and process the group enrolment and eligibility electronically with Care first connect system/ NASCO/FACETS for Medical, Dental.

·         Process management, Requirement gathering with PRD, Development estimation, execution, implementation and group assessment plans for groups with NASCO, FACETS5.0, and Care first Connect portal, PCF, STEPWISE-OPTUM and NASCO/ Facets/Members Edge/Cobol systems.

·         Performed TDM role for April 24 release and coordinated the production deployments PEGA BE

·         Used SDLC waterfall methodology from Care first side and Agile Scrum methodology from CFC vendor side to implement the CFC and NASCO projects using PEGA 6.1.

·         Coordinated Daily DRB calls on defects with QA team and Development team.

·         Requirement gathered and implemented the jurisdiction check based on the position of the PDPD ID (Product ID) and EPICS to send error message accordingly and all are implemented in PEGA BPM Broker Express system.

·         Performed GUI enhancements with Broker Express system for FES, SFDC, VIP requirements etc

·         Microsoft SharePoint 2010 used to manage the project related deliverables to client and maintained internally for the audit of PII or PHI and SPI data.

·         Participated Business meetings including sales for new business/benefit changes or Product changes (Blue Choice HMO to PPO, HMO OA, HMO OA HAS & PPO to HMO) and drafted BRD and provided to development team for development work and worked and UAT tested

·         Coordinated all the deliverables to SIT A and SIT B and Production Regions including conducting with Smoke testing with PEGA Broker Express, TIBCO, Facets, CFC systems.

·         Coordinated the UAT testing with business and Sales team and validated Requirements Vs System functionality and coordinated with QA team for any testing activities.

·         Used SOAP UI for rate pushes for testing and validating the broker express system when OPTUM unavailability

·         Successfully coordinated migrations of group enrollments from Facets to NASCO and Care First connect portals with Small Mid groups with Billing/Finance management.

·         Very good experience interacting with group contacts/broker on requirement gathering and Requirement verification on the GUI/BPMN based screens and implementations.

·         Coordinating end to end testing with 2-50 and Mid-market group files from CFC portal and verified all the enrollment data from group are accurate.

·         Managed all Care first BCBS/Blue choice plans including dental/vision/CVS Caremark Drugs data and conducted testing and audits to maintain 100% accurate with systems

·         Analyzing the system/business requirements with Facets/NASCO/Mainframe for Migrations of groups

·         Coordination with system, regression and UAT testing team and creating test plan for CFC Team.

·         SQL server and various SQL queries used to validate the enrollment  values in the backend DB

·         Worked on developing and testing functionality for the subgroups module like PBM (pharmacy benefit), FACETS5.0, Medicare and MMIS, 340B Federal Discount Process etc.

Environment: Pega 7.x, Tibco, Care first Connect Java portal, FACETS 4.7/5.0, NASCO, NPS, HP ALM, SQL Server, Web Share point, Mainframes, EDI, Ultra Edit, MS Visio, EDI 834, RFP, EPICS APD, DD and OAAPI, BAM, Agile, JIRA, RUP, HPXR, BPMN, SalesForce.com, OPTUM, SOAP UI and GUI, Members Edge

 

April 2014 – Sep 2014 Enrollment portal Development for Enrollment & Benefit Migration Project- Testing        Trion- Marsh & Mclennan Agency, King of Prussia, PA.

Trion-MMA has a group enrollment processing system to complete the Open enrollment and Benefits/eligibility electronically with Trion Market link system for Basic Subscriber life, Dental, Healthcare Reimbursement Account, HSA, Medical, RX, Vision and Premium FSA.

·         Providing process management, estimation and coordination of the projects with offshore team.

·         Interacted with group contacts/broker on requirement gathering and requirement verification on the UI enrollment & benefits for enrollment NASCO/Mainframe portal implementations.

·         Led end-to-end testing with liferay portal and verified all enrollment data from group is accurate.

·         Performed audits based on enrollment/benefits changes with group and update systems to match enrollment data.

·         Preparing the BRD and TRD and functional documents

·         Creating current and future state diagrams using UML and MS Visio.

·         Making sure the liferay system for open enrollments/yearly group renewals.

·         Planning for ID card processing for all open/passive enrollment and yearly renewal members including new enrollments with liferay portal.

·         Developed new websites using new company logo TRION instead of Marsh & Mclennan Agency and created many public forum/social communities to improve the enrollments

·         Coordinated system, regression and UAT testing team and create test plan for Liferay portal.

·         Worked with SQL server and SQL queries to validate enrollment values in the backend database.

·         Established and tested functionality for sub-groups modules such as PBM (pharmacy benefit), Facets, Medicare and MMIS.

·         Created risk assessment plans for group implementation with liferay and NPV portals.

·         Jira used for tracking the tasks and creating sub tasks and assign the time for offshore team

·         Created phone and ipads/tabs compatible Trion portals/websites and conducting testing for the same to improve the enrollments from Oct to Dec duration.

·         Agile and Scrum methodology used to execute the Pega automation implementation.

Environment: Java portal, JIRA, NPV, Plan Source, SQL Server, JCL, Web Sharepoint, SOAP UI, Quality Center, Ultra Edit, MS Visio, EDI 834, BRD, TRD, Agile and Scrum and PEGA CPM/BPM

 

Jun’13 – Mar’14        Pega Senior Business/System Analyst, Care first BCBS, Owings Mills, MD

Enrollment & Billing Group Configurations/Implementation-Business/System Analysis-Testing

Care first has the group enrollment processing system and process the group enrolment and eligibility electronically with Care first connect system to NASCO for Medical/Facets for Dental.

·         Process management, RFP Development, estimation, execution, implementation and risk assessment plans for groups with NASCO, FACETS5.0, and Care first Connect portal.

·         Used SDLC waterfall methodology from Care first side and Agile Scrum methodology from CFC vendor side to implement the CFC, SalesForce.com, and NASCO projects.

·         Microsoft SharePoint 2010 used to manage the project related deliverables to client and maintained internally for the audit of PII or PHI and SPI data.

·         Participated NAEGS meetings with sales/LGIT team for new benefit changes or Product changes (Blue Choice HMO to PPO, HMO OA, HMO OA HAS & PPO to HMO) and Medicare (Part A to D), Medicaid-Obama Care changes relate to groups/companies PII or PHI and SPI data.

·         Analyzed the group structure prepared by LGIT based on the benefit/product changes related to groups/Companies and prepared the process documents(RUP) to implement the same with CFC

·         Prepared the group implementation profile(functional specification) and coordinated with Care first connect team for medical/dental 834 file implementations with NASCO Facets/Members Edge/HPXR/NetworX Pricing/PEGA/ Billing/Finance

·         Writing technical specifications to create the SEED file for the group implementations

·         Successfully coordinated migrations of group enrollments from Facets to NASCO and Care First connect portals with Small Mid groups to large groups

·         Very good experience interacting with croup contacts/broker on requirement gathering and Requirement verification on the GUI/Mainframe based screens and implementations.

·         Coordinating end to end testing with large group files STEP/834 files from CFC portal and verified all the enrollment data from group are accurate.

·         Coordinating the Audits based on enrollment/benefits changes with group and updating the systems to match with enrollment data with BAM, PEGA, 824 errors

·         Managed open enrollments/yearly group renewals with eEnroll/eExchange/HRIT groups for all Active/Cobra/Medicare/Medicare splits members

·         Involved in the ID card processing for all the open/ passive enrollment and yearly renewal members including new enrollments PII or PHI and SPI data.

·         Managed all Care first BCBS/Blue choice plans including dental/vision/CVS Caremark Drugs data and conducted testing and audits to maintain 100% accurate with systems

·         Analyzing the system/business requirements with Facets/NASCO/mainframes for Migrations of groups and EPICS

·         Coordination with system, regression and UAT testing team and creating test plan for CFC Team.

·         SQL server and various SQL queries used to validate the enrollment  values in the backend DB

·         Worked on developing and testing functionality for the subgroups module like PBM (pharmacy benefit), FACETS5.0, Medicare and MMIS and 340B Federal Discount Process etc.

Environment: PEGA 6.2, Care first Connect Java portal, FACETS 4.7/5.0, NASCO, NPS, Members edge, COBOL, CICS, SQL Server, JCL, Web Share point, Quality Center, EDI, Ultra Edit, MS Visio, EDI 834, RFP Tumbleweed, BAM, Agile, JIRA, SFDC, RUP, HPXR, IBM 3270 TSO and EPICS.

Grasshopper, User Stories, Epics and JIRA 6.1.2, Facets/Members Edge

 

Jan ’12 – May ’13         Lead/Manager, BCBSIL, Chicago, IL

ICD 10 Business/System Analyst on EFE System

On October 1, 2013 a key element of the data foundation of the United States’ health care system will undergo a major transformation. We will transition from the decades-old ninth edition of the International Classification of Diseases (ICD-9) set of diagnosis and inpatient procedure codes to the far more contemporary, vastly larger, and much more detailed tenth edition of those code sets or ICD-10, used by most developed countries throughout the world.

·         Project management, RFP Development, resource, estimation, execution, implementation and risk assessment plans for ICD 10 project and used Agile Scrum methodology to implement the project

·         Very good experience interacting with vendor or stake holder on requirement gathering and Requirement verification with GUI/Mainframe based screens.

·         Managing project with agile-scrum methodology for successful execution with Joint Application Sessions(JAD) to collect and report requirements, perform data analysis/reconciliation of BRD  

·         Created future state diagrams using MS Visio, RUP and UML to use it for future state development

·         Created the use cases based on the requirements gathered with various client/state holders and reviewed with various stake holders using JAD sessions.

·         Worked on the defect fixes for the release and used visual studio for code debug/validation

·         Test and execution plan has been created for the ICD10 project to execute, SIT, Regression & UAT testing on the EFE mainframe system.

·         Reviewed logical design documents and use cases and making sure the  enhancements based on the ICD10 changes with business team

·         Coordinated with performance team using load runner to make sure the performance of the claims

·         Involved in smoke, unit test results reviews and validated with smoke and unit test results with Dev, Test & business team

·         SQL server and various SQL queries used to validate the ICD 9 & ICD 10 values in backend DB

·         Cycle’s execution for the latest ICD 10 project and defects tracking and validating the results.

·         Involved in analysis, detailed design, development, testing

·         Worked on developing and testing functionality for the subgroups module like PBM(pharmacy benefit), HL7, FACETS5.0, Medicaid and MMIS, 340B Federal Discount Process Etc

·         Extract, Transform and Load (ETL) and BI tools have been used in the projects on loading the data and maintain the data for reporting and STAR Schema, Cognos also used to manage the data and testing with the data ware housing system.

Environment: Java 1.6, COBOL, CICS, SQL, NetworX Pricing, HPXR, EDIFECS 7.0 & 8.3 QTP, Quality Center, EDI, GEMS, Agile, JAD, Facets 4.51, ITIL, ETL, Cognos, BI, JIRA, Visual Studio, RUP

 

Jan ’10 – Dec ’11        Lead/Manager, BCBSIL, Chicago, IL

4010 to 5010 Business/System Analyst on EFE System

In January 2009, the final rule was published requiring the health care industry to adopt version 5010 of the X12 standard transactions by January 1, 2012.Scope is meeting the mandate of CMS 5010 and accepting and sending HIPAA transactions in the standard formats. The transactions in scope are:

·         837 – P-I-D, professional/institutional/dental claims and ITS claim submission

·         835 – claim remittance and 834 – enrolment submission

·         270/271 – eligibility/benefit inquiry/response and 276/277 – claims status inquiry/response

·         Created project management, resource, estimation, execution, implementation and risk assessment plans for 5010 project  

·         Managed project with agile-scrum methodology for successful execution with Joint Application Sessions(JAD) to collect and author report requirements, perform data analysis / reconciliation  

·         Created future state diagrams using MS Visio, RUP and UML to use it for future state development use

·         Created the use cases based on the requirements gathered with various client/state holders.

·         Involved in detail system/business analysis, detailed design with Development team for UAT testing

·         Created detailed test and execution plan for the 5010 Regression & UAT testing on the EFE system and mapped the system requirements UAT cases in Quality center.

·         Created detailed test schedule for regression and UAT of 5010 project for 2012 implementation

·         Analyzed the 5010 business requirements and created the impact analysis document to create the error free test cases and scenarios for the EFE system.

·         Worked on the defect fixes for the release and used visual studio for code debug/validation

·         Validating the results of the Junit tests and suggested Dev team for code changes required by business

·         Analyzed the 837 I, P, dental and ITS claim changes in the 5010 implementation in Facets 4.51.

·         Very good experience interacting with vendor or stake holder on requirement gathering and Requirement verification on the GUI/Mainframe based screens and used ITIL.

·         Created automation process with QTP execute the test cases for 5010 project

·         Managed five  members team and verified the test cases n test scenarios created for 5010 project

·         Coordinated with performance team using load runner to make sure the performance of the claims

·         Created test and execution plan for the 4010 / 5010 regression comparison to make sure the new changes in the 5010 project.

·         SQL Server and various SQL queries used to validate the ICD 9 and ICD 10 values in database

·         Created SDLC & PMLC documents for 5010 projects

·         Coordinated reviews/ re reviews with Dev, test and business team and implemented the 5010 project

Environment: Java 1.6, COBOL, CICS, SQL Server, NetworX Pricing, HTML, EDIFECS 7.0 & 8.3 QTP, Quality Center, EDI, GEMS, Agile, FACETS 4.51, JAD, ITIL, Jira, Selenium, Junit, ETL, BI, APD, DD and OAAPI

Sept ‘09 – Dec ’09      Pega Business/System Analyst, CareFirst BCBS-FEPOC, Washington, DC

Enrollment & Compliance Team

Care first BCBS has the group enrollment processing system and process the group enrolment and eligibility electronically for FEPOC with connecting the following systems NASCO for Medical/Facets for Dental.

• Analyzed the current CareFirst–BCBS system with all the EDI transactions (834, 835, 270/271, 276/277 and 278) and gathered the requirements from the system as well as end clients
• Analyzed the current FEPOC Enrollment/ Billing/Finance processing and EDI transactions in to make sure the PHI compliance and other related data issues.
• Analyzed software development life cycle / project management life cycle processes in the Care first/BCBS-FEPOC with HIPAA regulations and making sure the accurate process to avoid the HIPAA PHI breaches with new 5010 project.
• Analyzed the enrolment system with membership data and created the business/use cases to enhance the process in the modernization project without PHI issues

·         Verified and Translated the business/user requirements into functional requirements to design the future state system at CareFirst FEPOC without any compliance

·         Analyzed the enrolment system with membership data and creating the business/use cases to enhance the process in the modernization project

·         Gathered information on the transactions of 270/271 (health care eligibility benefit enquiry and response) and 276/277 (health care claim status enquiry and response) current state information to implement the 5010 changes in the segments and loops without any PHI issues

·         Validated the test results for the new implementations for the 270/271 & 276/277 as part of 5010 changes and Medicaid and MMIS for PHI issues and conducted audits on Enrollment data

• Coordinated with testing managers for the test plan and test cases creations for the 5010 implementation project using Quality center and verified the test data also for PHI issues

Environment:  Java 1.6, COBOL, CICS, SQL Server, Web Services, XML, HTML, Quality Center, EDI, GEMS, Agile, Facets 4.71, ETL, BI, STAR, ITIL, PEGA, Visual Studio 2010, COBIT, EDIFECS 7.0

 

Oct ‘07 – Sept ’09       Senior Business/System Analyst, BCBS, Chicago, IL    

BRM, Business Rule Mining, Chicago, IL

Health Care Service Corporation (HCSC) is a non-investor-owned mutual insurance company that operates through its Blue Cross and Blue Shield divisions in Illinois, New Mexico, Oklahoma, and Texas, and several subsidiaries to offer a variety of health and life insurance products and related services to employers and individuals. It is an independent licensee of the Blue Cross and Blue Shield Association.

·         Created project management, RFP Development, resource, estimation, execution, implementation and risk assessment plans for BRM project

·         Managed project with agile-scrum methodology for successful execution with Joint Application Sessions(JAD) to collect and author report requirements, perform data analysis / reconciliation  

·         Six sigma green belt as well as reverse engineering techniques used for gathering the requirements and redefine the future state model using latest tools   

·         Created future state diagrams using MS Visio, RUP and UML to use it for future state development use

·         Created the use cases based on the requirements gathered with various client/state holders.

·         Validated business rules and extracting the legacy functionality with HIPAA Edi transactions for DC, Claim Lock, GCPS and DME, RX-Pharmacy Claims

·         Defined the current, future state business processing models using UML, MS office for the Medicare A-D claims including DME/Illinois public aid claims/Medicaid claims

·         Implemented new approach of business rules gathering from legacy system to CCSP and saved time as well as 2 million dollars’ worth of time

·         Defined the business, user, and functional requirements using appropriate documentation techniques to describe statements of the goals, objectives, or needs of a particular stakeholder or group of stakeholders using the low and medium complexity

·         Translated the high-level business requirements into functional specifications for the IT organization and manage changes to such specifications

·         Extracted claims from mainframe using JCLs and tested with BIS compare tool and verified the results of legacy and Java PRAP (Pre Adjudication) system and raised the defects using QC

·         Tested and verified the results of Bis (Batch Input System) compare tool, with claims and service lines information for the IL, TX, NM and OK claims

Environment: Java 1.6, COBOL, CICS, SQL Server, XML, HTML, EDIFECS 7.0, Quality Center, EDI, Agile, Req Pro, JCL, DB2, VB, Fileaid, OS/390, ETL, STAR, ITIL, HPXR, Six Sigma, APD, DD

 

Aug ‘04 – Sept ’07     QA/BA Lead/ Functional, UAT Testing, United Health Group, Hartford, CT   

UHG-TOPS (Online Claim Processing System)

Pr