Pratik Thakur Email & Phone Number

Greater San Diego Area

•Managed multimillion-dollar IT transformation and re-engineering initiatives for a top-tier healthcare organization to deliver profit growth, process efficiencies, and improved regulatory compliance•Established strong client relationship while working with cross-functional teams in execution of diverse projects including systems implementations, process improvements, report remediation, quality assurance testing and end user training•Created business intelligence reports for billing, claims, subscriptions using SQL that helped the management to make vital - business related decisions •Created visualizations using Tableau to understand customer demographics, claims and system performance•Ensured precise Data Transfer from the legacy GE IDX system to the HealthRules Payor system•Captured requirements by creating/updating a series of documentation for System Implementation projects such as the Requirements Traceability Matrix, UML Diagrams, Reporting documentation, Configuration Workbooks, Business Process Workflows, and Test Script Templates•Conducted meetings with SME's to understand and document the workflow of their business processes •Configured the benefit plans, billing rates, supplier contracts, subscriptions, enrollments, accounts, healthcare providers in the HealthEdge system •Worked on automating enrollment from incoming EDI files to HealthEdge using EDI management partners like CureIS•Ensured accurate claims adjudication by configuring service categories, cost shares, DOFR•Created mapping documents to ensure data consistency between the Payor and CareManager•Validated data across business applications like HealthRules Payor, CareManager and Salesforce•Lead multiple rounds of UAT by identifying the appropriate stakeholders and created test scripts for each stakeholder to execute. Analyzed all Pass/Fail results from the users and conducted many rounds of defect testing to flush out any issues within the system and received final sign-off

Costa Mesa, California, United States

The client is one of the largest health plans company in the United States and is making significant investments in modernizing its healthcare systems. As the client’s business model and the overall healthcare market evolves, core assets need to be modernized to keep pace with the new demands and to eliminate barriers to scale, performance, and innovation. The client pursued to solve their challenges with manual claims processing by leveraging innovative approaches through artificial intelligence, machine learning and robot processes automation.•Designed current state IT operating model based on data captured from current state interviews and identified key claims processing workflows •Facilitated business and IT conversations between multiple teams, conducted interviews with SMEs to identify client manual processes and integrations •Owned the process of data collection and preparation of data to be applied to data mining techniques like multiple linear regression, logistic regression, K-means clustering to understand the relationship of various claim variables and the finalized claim decision . •Performed exploratory data analysis to understand compositions of manually processed claims. •Perform feature engineering to identify most relevant inputs for Machine Learning algorithm performance•Retrieved data from Teradata to conduct false positive reviews on the test data•Supported process improvement discussions for enhancing data collection quality to reduce manual rework•Analyzed and detailed use cases to identify current state pain points and identify gaps in processes, KPIs / Tools, Governance•Facilitated daily stand-up meetings and responsible for creating weekly status reports

Project 1: The scope of the project was to replace the existing in-house system with QNXT Administrative system by Trizetto for Utilization Management. The legacy system faced serious limitations in coordinating interactions among members, employers, brokers and providers whereas QNXT application helps increase administrative efficiency and improve the quality of care. The project was focused on documenting the enhancement specifications for the new (To-Be) system from the existing (As-Is) System by enhancing workflows. Project 2: The scope of the project was to enhance of the Claims Processing module, which included claims processing and submission to Health services for Medicare and Medicaid. The application was implemented to make claims processing more efficient in compliance with CMS standards. Some of the features and functionalities introduced were eligibility verification, medical records, and billing verification.

Master’S Degree

Master'S Degree

Bachelor'S Degree