Job Description :
Knowledge of Business
Basic knowledge of health plan operations is required.
Provide complex support for Core System and/or Affinity Health Plan applications.
Applies understanding of all aspects of application requirements and their relationship to business requirements.
Works closely with peers and effectively evaluate client’s need and business processes. Translate, communicate, and document the requirements to BRD’s and FDD’s.
Generate interface designs, prototypes, data flow diagrams and system models.
Produces support documentation including screen layouts, report layouts, data element descriptions, and required algorithm definitions.
Demonstrates proficiency with the principles and methodologies of process improvement. Applies these in the execution of responsibilities in support of a process focused approach.
Technology - Tools
Strong knowledge on FACETS and/or Affinity Health Plan applications, as well as SQL.
Ability to individually scope and implement minor enhancements using best practices.
Executes comprehensive and thorough testing of programs and applications prior to customer acceptance/approval.
Provides comprehensive and well-written documentation, which identifies changes to programs
Performs duties under minimal supervision and guidance from management using detailed report request requirements.
Ability to research and analyze all aspects of existing business practices and procedures.
Experience includes the following:
Transform the entire system from mainframes to third Party software Facets that uses SQL Server.
Working on HIPAA compliance using HIPAA Gateway for transaction sets 276/277, 820, 835 and 837.
Resolved conversion issues during loading Providers, Members, Claims, Accumulators, Utilization Management, Accounting, Billing and Capitation modules to Facets database using SQL Stored Procedures and update the data according to the Sybase tables using Sybase Stored Procedures.
Work with business to gather requirements for report developments and worked with the development team ensuring the correct reports are being generated. Created test data in the process to load claims and members and providers for the development team for developing reports.
Utilize VB to create customized Facets screens for CLAIMS and PROVIDER modules.
Data analysis from legacy systems, mapping legacy mainframe fields to Facets tables in Members and Claims modules using EC-MAP tool.
Built Facets customized screens with Visual Basic 6 used as a part of the Erisco/Facets Claims System implementation. These Windows were for both online and edit processes that utilize a Sybase database.
Involve in complete Research, Analysis and Design of Accumulators, Eligibility and Claims Encounter Process, which includes gathering requirements, Documenting the Business Requirements, Analyzing the difference between the current process and preparing the Business Requirement Documents which includes detail information on the changes needed to be made to the new process.
QA tester responsibilities including creating test plans, test cases, and test data for 835 and 837 claims.
Strong evaluation of output requirements and formats according to the business clients. Able to handle about 25 clients including 170 PLANS which involved preparation MATRIX documents containing the total information of inbound and outbound process.