A professional team player with 11 years of IT project implementation and operational readiness experience. Experience in SDLC process for Health Care Individual and Group Products and specialized work with Finance, EMB, Contact and Customer Experience business processes. Excellent verbal and written communication and interpersonal skills with both business and IT stakeholders with proven documented forms such as business requirements specification, user stories, process flows and vendor change requests. Experience in review and assessment of enterprise level business cases for satisfying different segment market gaps.Strong institutional knowledge of Medicaid; including Medicaid Information Technology Architecture (MITA), and Medicaid Management Information Systems (MMIS)Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrollment, 835 Claim Payments, 829, 270-278 and many other healthcare maps.Understanding of EDI business practice and the ability to understand the client's needs.Strong Experience in Vendor relationships management and integration of new vendor . Experienced with Federal contracts, X12 transactions, health care act, EDI transactions 270, 271, 834, 835, 837.Wrote BRD, FRD, Mapping doc., test scenarios, test cases for testing the functional and non-functional aspects of both ETL and Reporting jobs.Worked on different EDI healthcare transactions like 834-Benefit Enrollment and Maintenance and 820-Payment Order/Remittance Advice.Upgrade mapping for new B2B and existing B2B clients , IBM Sterling B2B integration and IBM Connect Integration( Certification , Authentication and integration )Involved in Various application Implementation and conversion of 4.21 and also in TriZetto Facets and TriZetto HIPAA Gateway 4.11.Conducted internal audits and prepared audit reports to ensure compliance with Medicare, Medicaid and other institutions.Background of documenting HL7 and X12 interface specifications.Knowledgeable for gap analysis in changing old MMIS data via ETL and testing new MMIS system integration for legacy data to new DB format.Expertise in Membership Enrollment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis.SQL application management, (added users, created backup and recovery plans, ran SQL scripts) Through knowledge of ICD-9, ICD 10 codes and CPT codes for both Mental and Medical Health.
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Senior Business ConsultantD2J Alliance (A&A) Dec 2023 - Sep 2024Texas-Developed long-term business strategies to position companies for success in competitive markets. Delivered successful projects by leading cross-functional teams and adopting best practices in project management.-Enhanced profitability with cost reduction initiatives, resource optimization, and process improvements.-Streamlined operational efficiency through the development of strategic plans and identification of opportunities for growth.-Improved client satisfaction by analyzing business processes and implementing customized solutions.-Identified potential acquisition targets, conducting due diligence and negotiating deals to drive expansion efforts.-Strengthened client relationships through effective communication, understanding their needs, and delivering tailored solutions.-Collaborated with stakeholders to develop key performance indicators that measured success and informed future decision making.-Leveraged data analytics tools to track performance metrics, identify areas for improvement, and inform strategic decision-making processes.-Managed risk effectively by identifying potential threats early on in the project lifecycle and developing mitigation strategies accordingly.-Analyzed and interpreted data to determine any problems or areas that need improvement.-Evaluated vendor proposals, negotiated contracts, and managed outsourcing partnerships tomaximize value creation for clients.
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Senior Business System ConsultantRekonnection May 2023 - Dec 2023Texas, United States-Maintained detailed and complete records of health care plans and prognoses.-Reviewed healthcare insurance coverage and offered advice on supplemental health care plans. ----Enhanced IT infrastructure security with regular vulnerability assessments and proactive patch management.-Improved overall cloud architecture efficiency by implementing cutting-edge technologies and best practices.-Reduced downtime by promptly addressing hardware and software issues, ensuring minimal impact on business operations.-Streamlined processes through automation of routine tasks, increasing team productivity and reducing manual effort.-Implemented robust backup strategies to safeguard critical data against loss or corruption, minimizing potential risks.-Improved overall cloud architecture efficiency by implementing cutting-edge technologies and best practices.-Oversaw technology budget planning and allocation to optimize resource utilization while meeting organizational objectives.-Ensured compliance with industry regulations by implementing comprehensive IT policies and procedures covering data privacy, security, and access controls.-Managed network and system performance, conducting troubleshooting, security patching, and maintenance.-Customized and repaired technology based on staff requests.-Identified computer hardware and network system issues, performing troubleshooting techniques for remediation.-Developed long-term business strategies to position companies for success in competitive markets. Collaborated with stakeholders to develop key performance indicators that measured success and informed future decisionmaking. -
Senior Business System Analyst (Claims Management System Analyst)Conduent Oct 2022 - Apr 2023RemoteConduent provides end to end Claims Management Suite for Health Care Claim Adjudication Processes. Conduent provides Scale, Industry expertise and proven solutions to transform your healthcare operations from 834, 837 to 835 transections and improve outcomes of the processes.• Worked on RQ analysis for 2 major projects of Conduent Inc. • Dashboard for organizational performance for VP Presentation. • Test Beta version of Claims Management System with live data from various sources and create demo for obtaining new clients. • Used SQL to test various reports and ETL load jobs in development, QA and production environment.• Determine member benefits and priced claims according to individual provider's contract under Medicare CMS guidelines. • Enhance UI matrix for better understanding of organizational performance across different teams for tracking progress. • Report to Director of Analytics on complex day to day problems of the team and assist on providing technical solutions. • Work on Out of box solutions for various client ask and create an MVP with technical team. • Worked with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.• Responsible for testing and analyzing data consolidation, organization, and presentation.• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams/Process Flow Diagrams. • Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.•Claims Management system Sale Demo and presentations to potential Future Clients.• Worked on clients projects for east pointe, SVCMC, GOLD COAST, MEDICARE ADVANTAGE, Vaya etc -
Senior System AnalystOptum May 2021 - Sep 2022Maryland, United States• Performed Gap analysis for the new functionality requirements.• Worked with HIPAA rules and regulations to draft business rules and claim processes.• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.• Responsible for validating claim processing transaction of MMIS.• Worked on the ETL implementation using SQL Server Integration Services (SSIS).• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.• Hosted the application online using Microsoft SharePoint excluding some functionality those were involved in integration of FACETS with legacy and third-party vendor applications.• State communication management and Issue Resolution. • R&A, Suggest Complex solution, Testing, Implementation , Release coordination, Add and Update Features, RQ, Query logic and integrity testing etc.• Worked for OPTUM Client State of Maryland behavior health claims adjudication project. -
Senior Business System Analyst/Product OwnerFlorida Blue Apr 2018 - Apr 2021Jacksonville, FloridaProduct Owner for developing the Dashboard for Florida Blue 834 eligibility domain.DDashboard was developed to monitor day to day activities of exchange of files/data, predetermines issues in open enrollment before it becomes highest level of severity. Payment Vendor management, Requirement Gathering both functional and non functional , security enhancement on current FTP/SFTP processes, Rick assessment, Training new employs, Coding automations, Compliance management, Gap analysis, Budget planning/Assist PMO duties.● Associated with full Compliance life cycle from gap analysis, mapping, implementation and testing for processing Payment Data.● Scrum planning, MVP, SWOT analysis, Gap Analysis.● Worked with the team on EDIFEC processing system and gathered requirements to comply with HIPAA.● Involved in integration with legacy and third-party vendor applications.● Establish documentation for Agile methodology for implementation with a very water-fall-centric development team.● Performed analysis of enrollment and eligibility data in the XML format to determine if data is compatible.● Responsible for the core activities of the test team including creating and executing test cases, analyzing and documenting results and drawing a traceability matrix to match the requirements with the final test scenarios.● Worked on report creation skills using Microsoft SQL Reporting Services (SSRS).● Participated in release cycles of software developed using Waterfall and Agile methodologies.● Proficient in writing SQL queries for testing and data validation.● Responsible for preparing Software Requirement Specification (SRS).● Employed UML methodology in creating UML Diagrams such as Use Cases, Sequence Diagrams, and State Diagrams, Activity Diagrams and business process and workflows.● Involved in project planning, coordination, and QA methodology in the implementation of the change in Payroll Processing Vendor in Florida blue. -
Edi ConsultantUnitedhealth Group Jul 2015 - Dec 2017NjProduct Owner, Conducting SCRUM meeting, SWOT analysis, HIPPA compliance, Gap analysis for current processes, Budget planning with PMO.● Performed SWOT and Gap analysis for the new functionality requirements.● Worked with HIPAA rules and regulations to draft business rules and claim processes.● Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.● Responsible for validating claim processing transaction of MMIS.● Worked on the ETL implementation using SQL Server Integration Services (SSIS).● Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.● Worked on different types of insurances such as, Group health insurance, individual health insurance, dental insurance, vision insurance, etc.● Hosted the application online using Microsoft SharePoint excluding some functionality those were developed to use by employees only.● Identified and documented the dependencies between the business processes.● Created and executed Use cases for product and benefits testing for Medical and Dental.● Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.● Responsible for Medicaid Claims Resolution/Reimbursement for state health plan using MMIS.● Conducted JAD sessions and Data modeling.● Used SQL to test various reports and ETL load jobs in development, QA and production environment.● Determine member benefits and priced claims according to individual provider's contract under Medicare CMS guidelines and Dental benefits.● Facilitated daily scrum, sprint planning and sprint retrospectives meeting.● Diverse experience in Information Technology with focus on Business Analysis, Business -
Electronic Data Interchange Business AnalystFlorida Blue Sep 2014 - Jun 2015Remote/JacksonvilleFunctional RQ gathering for product owner, act as liason between Business analysts, Developers & Testers for new HIX tool implementation.
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Business Analyst/ Edi AnalystHumana Behavioral Health Jul 2013 - Aug 2014Ky LouisvilleEDI Business analyst position to meet HIPPA compliance, Validation task on requirements and testing for Business/Product owner.
Jay D. Education Details
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Professional Scrum MasterA+ -
Gpa 3.41 -
Science -
Microsoft Certified AcadamyA+
Frequently Asked Questions about Jay D.
What is Jay D.'s role at the current company?
Jay D.'s current role is Senior Business Analyst @Health Care | Professional Scrum Master.
What schools did Jay D. attend?
Jay D. attended Professional Scrum Master, Karnavati University, Gujarat University, Microsoft Certified Acadamy.
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