ABISHEK DAHAL
Reynoldsburg,OH
Summary
Medicaid health system specialist with extensive experience at Ohio Department of Medicaid, utilizing data analysis and visualization to improve program effectiveness. Skilled in cross-functional collaboration and ensuring regulatory compliance, with a strong ability to identify trends and anomalies. Proven success in enhancing Medicaid claims and services through data-driven insights.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Medicaid Health System Spec
Ohio Department of Medicaid
11.2024 - Current
- Analyze Medicaid claims, utilization, and cost data to identify trends, patterns, and areas for improvement.
- Assess the effectiveness of Medicaid programs and policies using data-driven insights to support decision-making.
- Identify anomalies in claims data to detect potential fraud, waste, and abuse in Medicaid services.
- Tracked healthcare provider performance and patient outcomes to ensure compliance with state and federal regulations, enhancing accountability in Medicaid services.
- Generated detailed reports and maintained records based on data requests, ensuring accuracy and compliance with Medicaid requirements to support program integrity.
- Developed reports, dashboards, and presentations to effectively communicate findings to policymakers, stakeholders, and leadership, facilitating informed decision-making.
Data Analyst
Magellan Health
10.2023 - 06.2024
- Employed report generators, data manipulation, and query tools for data extraction and reporting, facilitating informed decision-making.
- Imported data from SQL Server and Excel into SAS datasets for in-depth analysis.
- Gathered and analyzed system requirements, defined problems, and developed potential solutions to support project goals.
- Collaborated with developers and IT architects to design system interfaces adhering to X12 standards.
- Validated EDI X12 files using healthcare tools like Edifecs Spec Builder.
- Developed logic for flat files and EDI transactions (837I, 837D, 837P) to meet specific business requirements, enhancing data integrity.
- Communicated technical information effectively with peers and management, both verbally and in writing.
- Authored comprehensive Test Plans and Test Cases for Integration, System, and User Acceptance Testing (UAT).
- Documented Functional Specifications for key processes, ensuring HIPAA compliance.
Facets Configuration Analyst
Optum Health
05.2020 - 06.2023
- Implemented Facets System, configured claims and benefits, and conducted setup testing to ensure accurate claims processing.
- Managed inbound/outbound interfaces and extensions load and extraction programs involving HIPAA 837 files.
- Utilized MS SQL for extracting claims reports for ETL and detailed analysis.
- Developed test cases/scripts for unit and system testing with minimal supervision.
- Created and modified existing program modules, adhering to software reusability guidelines.
- Maintained business rules documentation and gathered comprehensive functional and non-functional requirement documents to support system integrity.
- Supported post-production of business applications, including maintenance and troubleshooting.
Software Developer
Hewlett Packard Enterprise
11.2015 - 12.2019
- Developed and maintained ASP.NET web applications using C#, .NET Core, and MVC architecture.
- Migrated legacy applications to .NET Core, improving performance and scalability.
- Conducted unit testing using NUnit/MSTest to ensure code quality and managed continuous integration pipelines for streamlined deployments.
- Debugged and resolved issues in development and production environments.
- Wrote SQL queries and stored procedures to update and verify information in MS SQL Server.
- Created and updated web templates and pages using VB, HTML, CSS, and JS to enhance user experience.
- Participated in code reviews, team meetings, and utilized version control systems like Git.
- Developed and maintained Windows services and WCF services for background processing and communication.
- Conducted code reviews and adhered to OWASP guidelines to enhance application security.
Education
Bachelors - business management
Strayers University
Skills
- Health data analysis
- Claims processing
- Claims analysis
- Healthcare interoperability
- HIPAA compliance
- Regulatory compliance
- SQL extraction
- Data visualization
- Tableau
- Power BI
- Agile
- Scrum
- Trend analysis
- Problem solving
- Cross-functional collaboration
- Effective communication
Certification
Certified Scrum Master (CSM), Scrum Institute, https://www.scrum-institute.org/certifications/Scrum-Institute.Org-SMACf44449145f-79658793102484.pdf
Timeline
Medicaid Health System Spec
Ohio Department of Medicaid
11.2024 - Current
Data Analyst
Magellan Health
10.2023 - 06.2024
Facets Configuration Analyst
Optum Health
05.2020 - 06.2023
Software Developer
Hewlett Packard Enterprise
11.2015 - 12.2019
Bachelors - business management
Strayers University