ALIJAN SETHY

Contact: (732) 314-3152

Visa: US Citizen
G-Mail: alijansethy59@[Link]

PROFESSIONAL SUMMARY

 Experienced Facets Business Analyst with over 8+ years of proven skills in requirement gathering, interacting with developers, documenting various
business processes, executing test plans and coordinating various projects contributing to Medicare in the region of Healthcare IT Sectors.
 Prepared client process maps for the consumer, broker, employer and provider transactions for the Facets process.
 Strong knowledge of FACETS and actively involved in end-to-end implementation of FACETS Billing, Enrollment, Claim Processing and
Subscriber/Member module.
 Strong systems expertise with various FACETS HEALTH RULES, and QNXT.
 Knowledge of health care services regulatory environment in compliance with HIPAA, ICD and EDI.
 Provide support and participation in the development of business process re-engineering opportunities (through the lens of Facets configuration and
functionality.
 Oversees the execution and completion of information technology solutions projects for the Healthcare/Payer Solutions area.
 Thorough knowledge of ICD-10 codes and CPT codes for both Mental and Medical claims Health and worked extensively with Inbound and outbound 834
Transactions processing systems.
 Experienced HR Business Systems Analyst & Employee Benefits, strong functional background in HCM/HRIS, Benefits Administration and Benefits
Systems along with experience with HR Systems implementations.
 Certified Scrum Master, working as part of Scrum Framework for a federal project (Identity and Access Management for CMS (Center for Medicare and
Medicaid Services).
 Actively worked on agile methodology, leading a team as Scrum Master.
 A motivational Scrum Master, coach and Lead, involved in monitoring, successful implementation and resolving issues arising throughout the course of
development for various projects.
 Experience in the domains of Insurance, Healthcare and Pharmacy Benefit Management (PBM).
 My extensive knowledge of claims and EDI has allowed me to gain extensive knowledge in X12 Financial Transactions series code systems which also
include HIPAA Transactions and Code Sets.
 Agile Methodology - (Scrum Master) / System Testing Business Rule Implementation / Business Analysis - MS Visio, MS Project, Metavante - Claims
Processing, Claims Adjudication.
 Experience in Revenue Cycle Management (RCM) for Scheduling, registration, eligibility, authorization, claims processing and payment
 Strong knowledge of managed care payer requirements and procedures.
 Experience in Power BI, Tableau and other data visualization tools in Business Intelligence
 Extensive experience working in all stages of the System Development Life Cycle (SDLC), Extensive experience leading and facilitating conducting Joint
Application Development (JAD) sessions.
 Extensive experience in conducting Market Research, Feasibility Studies, Data Analysis, Data Mapping, Data Profiling, Gap Analyses, Risk Identification,
Risk Assessment, Risks Analyses, and Risk management
 Experienced working in Provider Digital processes and enhancement of provider processes and architecture
 Business Design for desired changes and updates in the system in the technical design and UAT testing for changes and updates to the system.
 Analyzed and worked with HIPAA-specific EDI transactions for claims, member enrollment, and billing transactions.
 Extensive experience in Tableau Enterprise Environment and Administration.
 Extensively worked as a Techno-Functional consultant in providing CRM solutions with excellent business domain experience in Siebel Automotive
Captive Automotive Finance industry-specific applications and Siebel Automotive applications.
 Strong knowledge of Agile PLM, and scrum processes and experience in redesigning product development processes as per the business requirement.
 Extensive experience in healthcare systems: FACETS, Medicare Part A, B, C, D and Medicaid systems.
 Experienced with Full Life Cycle and Methodology for implementing Data warehouse and Business Intelligence Reporting System.
 Experienced working with FHIR standards and data mapping.
 Proficient in Risk Management planning which includes Risk Identification, Assessment, Risk Analysis, Reporting, and Risk response/monitoring/
control.
 Served as a liaison between the internal and external business community (Claims, Billing, Membership, Customer service, membership management, and
provider management.
 Experience in Eligibility and Benefits systems, ICD-10, HCPCS, CPT, HIPAA 4010 and 5010, Claims Adjudication and expert in Affordable Care Act (ACA),
Healthcare Reform (HCR).
 Enforced rules of the scrum, chaired key meetings, and challenged the team to improve its process.
 Ensure system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
 Excellent knowledge of Software Development Life Cycle (SDLC) and Agile Methodology.
 Responsible for assuring all required design inputs are captured and incorporated into product labeling development and design changes.
 Facilitate and lead project meetings with various CMS stakeholders to elicit project information and resolve project issues.
 Coordinated and monitored Affordable Care Act (ACA) Mandates within Health Care Reform Program.
 Experience working with EDI standards (ASC X12, NSF, HL7).
 Having extensive domain knowledge in EPIC, EDI X12, HL7, HIPAA, Health Edge, ICD-10, System, Medicare and Medicaid, CMS
Compliances/Regulations. Defined Functional Test Cases, documented, Executed test script in QNXT system
 Thorough knowledge of ICD-10 codes and CPT codes for both Mental and Medical claims Health and worked extensively with Inbound and outbound
transactions processing systems.
 Experienced working with SQL server Database- read access.

CAREER SUMMARY

Aya Healthcare - Indianapolis, IN

Business Analyst ( May 2022 – Present)
Responsibilities:
 Experience working in the enhancement of payer space content management system and CMS interoperability
 Experienced doing SQL analysis across various database systems
 Experience in requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.
 Have an in-depth understanding of FHIR standards and implementation.
 JIRA for documenting requirements gathered from business users.
  Lead Backlog Refinement Session with Product Owner and Scrum Team to Refine and prioritize the user stories present in the product backlog using
Moscow Technique.
 Experience with TriZetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions
 QNXT, Care Advance, CWS, Facets and a host of 3rd party software suites are included with the build outs of the environments.
 Acted as a liaison between client and payer/intermediary. Experienced in payer rules, requirements, governmental regulations and HIPAA compliance.
 Worked on Healthcare system crosswalk in Electronic medical claims Records (EMR) and Electronic Health Records (EHR) software.
 Direct contact with the payer on behalf of the provider to discuss claim rejection reasons concerning claims and enrollment.
 Excellent Knowledge of Electronic Medical claims Record (EMR)/Electronic Health Records (EHR) modules and process flow.
 Mentored New Staff as their Certification
 Generating reports from System Database resources using SSRS reporting features
 Involved in creating rules (e.g.: copay, deductible, quantity limits) for Pharmacy Claims testing.
 Worked on the analysis and documentation of the Revenue cycle management (RCM) products line.
 Experienced in Claims Master and Revenue Cycle Management (RCM) suite.
 Worked with Oracle Support in analyzing and identifying root causes for Agile PLM issues.
 Analyzed the problem domain, specified features, established baseline architecture, developed the Project plan, and risk analysis.
 Created dependency diagrams in Visio showing interdependencies within NextGen sub-projects, components and timelines visually.
 Experience working in the enhancement of payer space content management system and CMS interoperability
 Assist configuration analysts with application functionality and testing.
 Gather technical and functional business requirements from business stakeholders through effecting brainstorming and focus group sessions
 Determine the User stories and Features based on the prioritized Epics provided by the program and product owners.
 Participated in functional design sessions, creates and executes SQL DB, and aids in the solution of data issues.
 Verified member’s information in Nextgen in-house application.
 Developed Azure Build and Jenkins jobs for Continuous Integration and Deployment in the Test and Production Environment
 Participated in Business Modelling by documenting the needs of the Business.
 Created Source to target data mapping documents identifying key data elements and prepared Data Flow Diagrams
 Developed working relationships with project team members across different sub-project teams and departments to facilitate communication and foster
collaboration including providing ongoing project consulting support and counsel to the Technical Lead of the NextGen project initiative
 Deep understanding of Enterprise Risk Management and its components such as Hazard risk, financial risk, operational risk, strategic risk
 Designed a new matrix covering all the conceptual parameters of the new system.
 Completed and worked as a PM- Scrum Master / BA on GSTS to Primavera (Momentum), and on 2 Productivity tools for SharePoint - Launcher and Notify
and 2015 Confidential Photo Manager as a SharePoint Scrum Master) / Business Analyst.
 Extensive knowledge of relevant cross-industry data and messaging standard organizations and the HIPPA/EDI industry. Specific organizations maintain
a point of view as to the current applicability and risks associated with implementing standards or new technologies in the client environment.
 Developed applications to track risk exposure.
 Worked with different IT Teams, Business groups, and clearinghouse Emdeon and HDX groups to understand and determine the Impacts of the ERA and
EFT Processes.
 Maintained the administration tool to control user access to Agile-PLM client services.
 Involved in the generation and validation of Confirmation reports Using Edifices Transaction Manager.
 Expertise in Claims Life Cycle, Healthcare Claims processing systems such as Health Edge, Health Rules, Health Trio and Health Suite.
 Assist the Product Owner in maintaining the product backlog, plan release backlog and participate in iteration planning sessions with the development
team. Work across multiple agile teams to support enterprise-level epic
 Work with the Product Owner to define product features and write epic user stories to monitor and track business value delivery. Meet with business and
IT stakeholders to solicit requirements and create user stories using the INVEST criteria.
 Configure complex Medicaid healthcare benefits on the enrollment system.
 Performed data analysis and data profiling using complex My SQL on various sources systems including Oracle and SQL Server
 Leverage Risk experience and business judgment to plan initiatives and accomplish enterprise-wide goals.
 Worked as BA and Scrum Master on various projects - Driven Backlog Grooming/Refinement Sessions, Releases, Sprint Planning, Stand-Up Meetings,
Sprint Demos & Retrospective activities
 Working knowledge of HL7 v2.0 standards.
 Coordinated with the development team in documenting End User Manual.

UC Health – Cincinnati, OH
Business Analyst (Apr 2021 – Apr 2022)
Responsibilities:
 Gathered Business Requirements, Interacted with the Users. Designers and Developers, Project Managers and SMEs to get a better understanding of the
Business Processes.
 Widespread knowledge of EHR/EMRs Electronic Medical Claims Records, HL7.
 Involved in documenting transformation logic for FHIR from source to Target Managed the company's EDI transactions catalog for prospective EDI
transactions837 customers.
 Worked with FHIR mapping and data migration from one database to another
 Create a Virtual Network on Windows Azure to connect all the servers.
 Handle escalated Support tickets till closure for MS Azure PaaS platform.
 Gathered and documented requirements to communicate the procedures to resolve late/missing EFT (Electronic Fund Transfer) and ERA (Electronic
Remittance Advice) transactions.
 Analyzed the change detection process on QNXT database tables to capture the daily changes done by Users through Online QNXT Application.
 Write and execute positive and negative test cases to ensure the data originating from the data warehouse Oracle dB is accurate through to the SQL dB in
the applications. Work with payers on File level rejections caused by improper file submission
 Pulled information for retail POS to gather data and generate reports to track trends of sales and targets.
 Gathered and analyzed the User Requirements from walkthroughs and interviews with the business groups and in-house stakeholders, and many other
departments like accounting, fund management and human resource and thus converted User Requirements into Business Requirement Documents
(BRD). Ensure day-to-day EDI transactions837, Reject tracking and Reconciliation.
 Worked closely with HP Extreme and Health Rules developers to understand system specifications.
 Helped develop integration solutions that create interoperability between Health Rules and HP Extreme
 Created and maintained requirement documents for Facets for the different modules like Billing, Member enrollment and Claim adjudication.
 Facilitated Scrum meetings with technical/non-technical teams. Accounts updating, data analysis and sharing with XML patterns, SMEs to clarify business
rules & solve impediments, rectifying the regulatory issues with SMEs and translating Functional requirements into User stories using JIRA.
 Prepared test data from user stories and write and execute test cases in JIRA.
 Worked closely with the team to implement health plan rules to the existing internal system
 Excellent leadership skills, with extensive & diverse experience in working with both management and technical roles. (Project manager, scrum master,
business analyst, techno-functional architect. Worked on re-implementation with HCM
 Provided Agile PLM Application Support - configuration, customization, and on-demand reports.
 Worked with the Manage File Transfer MFT team to establish URLs, ports and credentials for secure file transfer between ACI and Horizon.
 Gathered requirements for defining rules, terms and business logic to implement the configuration
 Created Business Requirements Document (BRD), Systems Requirements Specification (SRS), and Requirements Traceability Matrix (RTM) with
assistance from the business group and IT team members.
 Coordinate with HRIS business users globally and provide support for the HR/HCM application.
 Create, update and monitor business processes for FTP and SFTP send/receive errors.
 Experience designing and developing SQL DB statements and queries for Oracle Sybase and My SQL Server 2000 database. Prepared documents to
conduct user acceptance testing.
  Deployed and designed pipelines through Azure data factory and debugged the process for errors.
 Involved in the creation of virtual machines and infrastructure in the Data model Cloud environment.
 Created various Reports (summary reports, matrix reports, pie charts, dashboards and graphics) and Report Folders to assist managers in better utilizing
Salesforce as a sales tool and configured various Reports and for different user profiles based on the need of the organization.
 Strong understanding of FACETS and Facets Data Model working on the data model and data extracts.
 Dealt with the EDI transaction-835 claims payments and remittance advice, which deals with the payment from payer to provider.
 Modified access and sharing rules, added custom objects and workflows and approved processes.
 Analyzed and documented Medicaid EDI transactions837 issues related to the implementation of HIPAA 5010 and ensure these issues are documented
and addressed in the approach to the HIPAA 5010 version
 Created UML Diagrams including Use Cases Diagrams, Activity Diagrams/State Chart Diagrams. Sequence Diagrams.
 Collaboration Diagrams and Deployment Diagrams, using Rational Rose and MS Visio and thus defining the Business Process Model and Data Process
Models. Interpret, analyze and implement contracts and government guidelines to ensure payer set-up is accurate.
 Implemented automated COB processing of Medicare claims into Facets.
 Created new report types, new reports and dashboards to monitor and issue regular key productivity indicator reports and charts.
 Maintained processes of CSV import file updates for customer records into Accounts, Contacts using Data Loader and Import Wizard.
 Performed user training of various Salesforce instances for clients and users.

Centura Health - Centennial, CO

Business Analyst (Jan 2018 to Mar 2021)
Responsibilities:
 Coordinated in designing an architecture that was flexible, scalable, performance-oriented, and provided a sustainable cost of ownership.
 Developed Requirements Tractability Matrix (RTM) using MS Excel to trace each software design requirement to test cases.
 Provided analytical solutions to the customers for Facets Production Issues.
 Experienced in the enhancement of applications and understanding the digital architecture of the provider system
 Responsible for architecting integrated HIPAA, Medicare solutions, and Facets EDI 834.
 Created documentation such as BRDS and FSDS (Business and Functional design specs) with elaborate Use Cases and process flows.
 Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
 Well-versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their
source and providing corresponding solutions.
 Gathered the Requirements for Medicare Systems as part of the Patient Protection Affordable Care Act (ACA).
 Implemented new services and programs for the Medicaid program by directly interfacing with the customer and the system engineers on a regular basis
 Sold RCM & web-based medical claims transcription services to hospitals & medical claims practices with 10-75 physicians.
 Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for both the HL7 ADT interface and the application.
 Conducted data Mapping and database change sessions, Identified the existing data fields in SharePoint data mart which is the centralized database for
Aventis applications and required data fields for TEN applications.
 Developed business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model
notation and enterprise architecture.
 Worked extensively with developing business rules engine enabling the business rules such as referral and prior authorization. Eligibility and billing are
essential.
 Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with
tracking burn up, burn-down charts to estimate sprint delivery.
 Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
 Conducted JAD sessions during the various stages of upgrading the matching system and discuss the current system preference.
 Run EDI Reconciliation reports daily and document them in MS Excel.
 Experience with TriZetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions.

CareSource - Dayton, OH
Business Analyst/ Scrum Master (Apr 2017 – Dec 2017)
Responsibilities:
 Created various documents like the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications,
Functional Specifications (FSD) and Systems Design Specification.
 Facilitated gathering Business Requirements from State, Users and Internal Offices.
 Analyzed legacy systems, file and record formats, system flow charts and other information to develop a comprehensive depiction of the existing
environment.
 Analyzed the client's applications to determine the impact of the Enhancements on EDI Transactions837 Set and Code List implementation and defined
the changes to bring the affected systems into compliance.
 As scrum master communicated dependencies and potential risks to the completion of the sprints including resources, costs and systems.
 Helping Scrum masters across the company to customize JIRA for their requirements.
 As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn-down charts.
 As Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming sessions, daily scrums product
demos, sprint reviews and sprint retrospectives.
 Playing the role of Senior Business Analyst and Scrum Master.
 Focused and goal-oriented Scrum Master, leading a sprint team consisting of development, testing, architects and infrastructure members working on agile
methodology.
 Worked in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
 Experience in requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.
 Involved in the processing of the claims and then sharing the test results with the business according to test acceptance criteria during their UAT phase.
 Created use case diagrams, activity diagrams, and flow charts to depict the interaction between the various actors and the system.
 Used Microsoft Excel to create Pivot tables, VLOOKUP and other Excel functions.

CVS Health - Hartford, CT

Business Consultant (Apr 2016 – Mar 2017)
Responsibilities:
 Experience in translating client requirements into different tangible deliverables such as functional specifications, user cases, user stories, and
workflow/process diagrams.
 Prepared for GAP Analysis identified and documented improving areas to meet capital requirement regulations.
 Monitoring and supporting Securities Trading, Order Processing, Customer Portfolio, KYC Know Your Customer, Credit Risk and other online Banking
systems.
 Conducted UAT to confirm that all derivative products can be successfully processed during the trade life cycle.
 Discussed with SMEs across different business units to gain a solid knowledge of the existing Credit Risk Calculation System and assisted in preparing an
advanced Risk Assessment and ROI Management.
 Responsible for business system analysis of customizing the BPS Risk Management product with involvement through the whole SDLC
 Followed the UML-based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, State Chart Diagrams, Sequence Diagrams and
Collaboration Diagrams.
 Conducted JAD sessions with management, SMEs, vendors, users and other stakeholders for open and pending issues.
 Worked extensively with the team for designing Test Plans and Test Cases for User Acceptance Testing.
 Verified the Business Scenarios on new builds to allow extended testing by the QA team
 Experience working on projects with blended Waterfall and Agile environments.
 Extensive experience in producing documents like Business Requirements Documents (BRD), Functional Requirement Specifications (FRS) and Software
Requirement Specifications (SRS).
 Conducted interviews with various business users to collect requirement and business process information using MS Visio, and Requisite Pro.
 Used Agile Development methodology throughout Project Life Cycle.
 Worked in an Agile/Scrum environment which posed initiating several JAD sessions and active interaction with business and technical teams
 Used the RUP approach to fabricate UML diagrams and use case storyboards.
 Provided value-added suggestions for process improvement to business partners and end users.
 Interfaced with end users and business owners to examine current work processes and communicated the results to the stakeholders.
 Conducted JAD sessions with management, SMEs, vendors, users and other stakeholders for open and pending issues
 Performed GAP analysis to define gaps between AS-IS and TO-BE processes.
 Proficient in writing advanced SQL queries with the ability to analyze large volumes of data.
 Demonstrated excellent technical writing skills by developing Business Requirements Document (BRD) and Functional Specifications Document (FSD).
 Responsible for modeling requirements using UML diagrams such as Use cases, Activity diagrams in the MS Visio tool.