Princy Thapaliya
Raleigh,NC
Summary
Experienced EDI Finance Tester and Claims Tester with over 6 years of expertise in testing financial and healthcare-related transactions, including claims processing, billing systems, and payment remittances. Proficient in validating EDI 837 (claims), EDI 835 (payment remittances), EDI 270/271 (eligibility inquiries), and other healthcare-specific EDI transaction sets. Skilled in performing end-to-end testing of healthcare financial systems, including integration with insurance companies, Medicaid, Medicare, and private insurers.
Strong background in ensuring regulatory compliance with HIPAA, and healthcare industry standards while validating claims submissions, payment processing, and reimbursement. Adept at data mapping, SQL querying, and system integration testing for seamless data exchange between healthcare providers, insurers, and financial institutions. Well-versed in tools such as JIRA, , SQL, TestRail, for defect tracking, test management, and EDI protocol validation. Known for attention to detail, troubleshooting skills, and the ability to ensure the accuracy and integrity of critical financial data in healthcare environments.
Overview
7
7
years of professional experience
Work History
Senior IT Specialty Analyst
Sentara
Norfolk, VA
11.2023 - Current
- Generated comprehensive reports for stakeholder review.
- Delivered recommendations derived from data interpretations.
- Identified opportunities for process improvements across the organization.
- Designed test plans to ensure quality assurance standards were met.
- Collaborated with cross-functional teams on projects related to analytics initiatives.
- Implemented strategies for automating manual processes within the organization.
- Utilized visualization tools such as Tableau or Power BI to present findings.
- End-to-end testing: Conduct end-to-end testing from the initiation of a financial transaction (e.g., a payment request) to its final processing (e.g., settlement, confirmation, or account reconciliation) through the entire EDI pipeline.
- Ensure that claims are correctly submitted, adjudicated, and paid according to the policy and the patient’s benefits.
- Ensure that systems adhere to the specific rules and formats required for Medicare and Medicaid claims and payments, including accurate coding and billing procedures.
- Ensure that claims are submitted to insurers using the correct EDI formats and protocols (e.g., HIPAA 837 claims, 835 remittance advice).
- Strong knowledge of healthcare billing processes, claims adjudication, and reimbursement.
- Expertise in testing EDI formats for insurance claims and payments.
QA Tester
Gainwell TECHNOLOGIES
EL PASO, Texas
05.2022 - 04.2023
- Applied knowledge of software engineering processes to develop comprehensive test strategies
- Organized and attended open defect meetings with developers and QA leads
- Performed functional, regression, integration and acceptance testing on various projects
- Worked in QNXT application to verify the data in QNXT UI
- Worked for Different QNXT Application like member enrollment, claims, encounter, and authorization
- Proficient understanding of insurance policies like HMO and PPO and proven experience with HIPPA 5010 EDI transaction codes such as 834(Benefits enrollment), 835(Payment/remittance advice), 837(Health care claim)
- Excellent understanding of HIPAA 5010 rules as well as ICD 9 and ICD 10
- Utilized defect tracking tools such as JIRA to document identified bugs during testing process
- Analyzed requirements documents, designs and specifications for accuracy and completeness prior to testing activities
- Ensured that all projects are delivered within agreed timelines
- Evaluated new technologies and methods to make recommendations regarding use
- Prepared comprehensive reports on test results for stakeholders
- Implemented continuous integration pipeline utilizing Jenkins CI server for automating builds
- Designed and conducted tests to evaluate product functionality, usability and performance
- Reviewed existing processes to identify areas of improvement in the QA process
QA Analyst
Emblem HEALTH
Manhattan, New York
03.2018 - 04.2022
- Provided technical support throughout the entire software development life cycle
- Collaborated with product owners, project managers, and other stakeholders throughout the development life cycle process
- Developed SQL queries for data validation purposes across multiple databases
- Monitored testing procedures to ensure that all tests were performed according to established item specifications, standard test methods, and protocols
- Implemented best practices for software development projects such as Agile Scrum methodology
- Developed and qualified new testing methods
- Documented all phases of QA process including test results, bugs found, and fixes applied
- Hands-on experience with testing of COB, Healthcare Claim Pricing, Healthcare Claim Benefits, End to End Claims Processing
- Interpreted test results, compared them to established specifications and control limits and made recommendations on appropriateness of data for release
- Educated agents, supervisors and managers on QA process and goals
- Identified quality problems and recommended solutions
- Reviewed bug reports to validate bug fixes and verify the correctness of the system behavior
- Identified areas of improvement in existing QA processes through continuous analysis of current practices
- Developed departmental objectives, budgets, policies, procedures and strategies
- Well knowledge of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions
Education
Bachelor of Science - Environmental Engineering
The University of Findlay
Findlay, OH01-2018
Skills
- User Acceptance Testing (UAT)
- Functional Requirements Specification (FRS)
- Manual software testing
- System Integration Testing
- QNXT
- Database Testing Software
- JIRA
- Daily Status Reports
- Office tools
- SQL
- Flexi
- Claim Test Pro
- Provider Portal
- ServiceNow
- Workday
- Availity
- SSRS
- Encounter Data Manager (EDM)
References
Siron Chettri, Emblem HEALTH, Team lead, 251-623-9497
Affiliations
Defect Tracking & Root Cause Analysis
Performance Testing
Test Planning & Test Case Design
Accomplishments
- Top 5 in every week and monthly QA Test Run Reports
References
References available upon request.
Timeline
Senior IT Specialty Analyst
Sentara
11.2023 - Current
QA Tester
Gainwell TECHNOLOGIES
05.2022 - 04.2023
QA Analyst
Emblem HEALTH
03.2018 - 04.2022
Bachelor of Science - Environmental Engineering
The University of Findlay
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