Summary
Overview
Work History
Education
Skills
Certification
Tools and Software
References
Timeline
Generic

Nirmal Gurung

San Francisco,CA

Summary

Experienced Senior Business Systems Analyst with 8+ years of expertise bridging the gap between business needs and technical solutions. Proven ability to drive cross-functional collaboration across product, development, and QA teams, facilitate stakeholder alignment, lead end-to-end analysis, and deliver enterprise-scale system enhancements. Recognized for analytical rigor, translating complex data into actionable insights, and optimizing workflows to support strategic business goals.

Overview

11
11
years of professional experience
1
1
Certification

Work History

Sr. Business Systems Analyst/Product Owner

Centene Corporation
03.2022 - Current
  • Led the development and enhancement of business processes and applications supporting 'Value-Based Payment' and 'Prospective Attribution' programs of Fidelis New York Health Plan, resulting in enhanced patient outcomes, improved member health, and reduced cost of care.
  • Drove meetings and workshops with stakeholders and vendor partners to design the product roadmap, gather requirements, build consensus, and align priorities.
  • Documented change requests and solidified functional and technical requirements to user stories in JIRA.
  • Conducted Scrum ceremonies, managed the product backlog, organized deliverables into Sprints, and ensured the right features were prioritized and released on time.
  • Tracked and ensured that business-critical processes met the SLA, performed root-cause analysis on production incidents , and designed corrective actions to prevent future incidents.
  • Led and executed the enterprise-wide transition of the Pharmacy Benefit Manager - analyzed data from the new PBM for quality and completeness, mapped data fields, formulated transformation rules, tested and validated output, and ensured seamless integration of the data from the new source into existing systems.
  • Played a key role in the successful migration of the team’s business applications from a legacy database to a new database system (Greenplum Building Blocks) - coordinated with cross-functional teams and DBAs in extensive planning, impact analysis, integration & stress testing of the system, and deployment of the changes to production.
  • Designed sFTP solutions for the secure exchange of both outbound and inbound data extracts and reports.
  • Performed data analysis using SQL in support of business cases, generated ad hoc reports, and optimized SQL functions and validation scripts for improved performance.
  • Formulated test plans and test cases, and executed testing, including Functional, System, Integration, Regression, and UAT.

Solution Designer

Blue Cross Blue Shield
Kansas City, MO
04.2021 - 10.2021
  • Successfully led and executed the project to include new Medicare Supplement plans offering, products, and members in the ‘Medicare Crossover Eligibility’ files – designed file specifications, analyzed relevant data points by working with SMEs, validated business rules, and tested end-to-end before pushing to production.
  • Streamlined report that included Medicare Advantage SPIRA members’ discharge and prior-authorization details which enabled vendors to proactively identify members, minimizing time and maximizing efficiency in coordinating care management plan for non-clinical transition-of-care services.
  • Drove the creation of automated outbound file feed for Annual Notice of Change (ANOC) and Welcome Kit letters for Medicare Advantage members and standardized the ANOC and Evidence of Coverage (EOC) documents.
  • Collaborated with stakeholders to determine priorities, manage team workload, report progress, and solicit feedback.
  • Created comprehensive technical documentation for systems and processes, ensured documentation is up-to-date and accessible to relevant teams in SharePoint and Confluence
  • Developed Standard Operating Procedure (SOP) documents for enhancements, automations, implementations, and compliance.
  • Translated business needs into detailed system requirements and functional specifications and worked with developers/QA to design technical solutions.
  • Routinely audited and analyzed business processes to ensure compliance and address any identified issues or areas for optimization.
  • Analyzed data in Facets, debugged SQL functions, wrote test and validation scripts, and advised technical strategies to developers and testers.

Sr. Business Systems Analyst

Centene Corporation
St. Louis, MO
10.2017 - 11.2020
  • Worked in production support and managed applications in Teradata warehouse that priced healthcare claims in coordination with 3M and Optum software and tools.
  • Developed methodologies to cross-price claims using Medicare and Medicaid Prospective Payment System rules.
  • Planned Agile sprints, prioritized and groomed product backlog, managed issues, cleared roadblocks, tracked, and communicated progress.
  • Captured business needs and requirements into user stories and MVPs (minimum viable product).
  • Integrated new line of businesses (Medicare, Medicaid, Marketplace, Behavioral health plans) to the methodology ensuring established CI/CD (Continuous integration/Continuous deployment) best practices were followed.
  • Led the Data Mart project which coalesced the claims data from multiple applications and migrated/populated them into a single platform which made access, analysis, and reporting easier for business users.
  • Ran and supported the back-end process that fed the priced data to the MicroStrategy dashboard and analytics platform which projected standardized metrics to track and measure cost performance of Health Plans.
  • Grouped Inpatient and Outpatient claims (DRG, APR-DRG, APC, APG, APG-PRO).
  • Did functional testing of ETL servers and OPTUM servers.
  • Analyzed the ICD conversion information provided by the CMS and gained understanding of ICD-9 versus new ICD-10 code sets.
  • Ran ad hoc tests, performed data analysis and validations using ToadSQL and Teradata SQL Assistant tools.
  • Logged and documented issues found during data validations, proposed solutions to stakeholders and the developers, and tested the implementations.
  • Researched and tracked the ever-changing CMS Prospective Payment System and Optum pricing rules and suggested code changes and process enhancements to keep the applications up-to-date and relevant.

Business Systems/EDI Analyst

Coventry Health
Bethesda, MD
03.2016 - 09.2017
  • Defined requirements for inbound 837 claims and MACESS files to feed into imaging and workflow software.
  • Managed external vendors correspondence regarding outsourced paper claims.
  • Released deliverables in sprints and iterations following Agile methodology.
  • Created Use Case diagrams, Sequence Diagrams, Activity Diagrams and Class Diagrams using UML and Business Process Models using MS-Visio.
  • FACETS Implementation, end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Planned, designed, and implemented department plans to configure new Facets integrated processing system, to include but not limited to, workflow management, oversight, and performance analysis.
  • Executed the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid claims and NCPDP claims.
  • Processed requests for medical services and pharmacy services submitted via DDE or HIPAA 837 EDI and NCPDP submissions, and mapped EDI files with Facets back-end database.
  • Documented configuration of billing modules regarding GL, AR/AP generation method, Fees, and discount etc.
  • Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
  • Collaborated with business partners and developers to create EDI X12, NCPDP D.0 and proprietary encounter submission files.
  • Created SQL scripts for various levels of testing including integration testing, system testing, end-to-end testing, and user acceptance testing.
  • Worked on Data Mapping to map Facets data to outbound eligibility extracts.

Sr. Business Systems/EDI Analyst

United Health Group
Phoenix, AZ
07.2015 - 02.2016
  • Reviewed Business Requirement Documents and Functional Requirements.
  • Prepared GAP documents involved with 834, 820 transactions in collaboration with other team members.
  • Gathered requirements, developed Process Model and detailed Business Policies.
  • Worked closely on 834 transaction code for Benefit Enrollment and was involved in validation of HIPAA for 837, 270/271, 276/277,835,834 EDI transactions.
  • Captured all HIPAA-related EDI data in the repository using FACETS.
  • Accepted inbound transactions from multiple sources using FACETS.
  • Supported integrated EDI batch processing and real-time EDI using FACETS.
  • Responsible for setting up Billing frequency, premium invoicing.
  • Maintained Requirement Traceability Matrix (RTM) to make sure that test plans were written for all the requirements.
  • Coordinated detailed End-to-End Test Cases and design steps walkthroughs and ensure signoff by stakeholders.
  • Developed, coordinated, and supported Information Technology Division on all operational requirements of FACETS claims processing system and production management.
  • Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
  • Extensive knowledge working with tracks that included Plan Management, Plan development, enrollment and Billing, and Regression testing.
  • Worked on Data Mapping to map Facets data to outbound eligibility extracts.
  • Produced daily and weekly testing status reports and communicated to upper management.
  • Wrote test cases and test scripts, executed test scripts and analyzed outcomes.
  • Performed defect testing for individual tracks that worked with notices, UI/UX and eligibility verification.
  • Facets support systems were used to enable inbound/outbound HIPAA EDI transactions in support of HIPAA 834, 835, 837 270/271 transactions.

Systems Analyst/ ICD10 Tester

Dignity Health
Phoenix, AZ
11.2014 - 06.2015
  • Responsible for documenting Business (BRD) and Functional Requirements (FRD).
  • Analyzed inpatient and/or outpatient medical records using International Classification of Diseases, Ninth Revision (ICD-9/10) and Update ICD-9 and CPT code changes.
  • Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions.
  • Maintained reimbursement summaries from third parties and compared with clinic fees, Updated reimbursement regulation, Notify Business Manager of significant changes, conduct periodic medical record audits to ensure documentation is consistent on billing.
  • Remediated all custom codes, inner/outer extension impacted by ICD10 by identifying and creating user stories for Developers in Team Foundation Server (TFS).
  • Well-defined and produced inclusive, accurate conversions of ICD-9 codes into equivalentICD-10 codes with the option to adjust system application for ICD-10 specificity using GEMS.
  • Assisted with the User Interface (UI) prototypes to capture and validate requirements and spike solutions to the occurring problem.
  • Tested claim billing processes as well as other healthcare processes such as enrollment, eligibility, and claims-to-remittance adjudication processes.
  • Created EDI Export and Import processes for the EDI Trading Partners, Payers/Vendors.
  • Created Test cases, and test plan from stage to production in MS SQL.
  • Performed Unit testing and documented it using Excel, created artifacts, and listing for UAT validation, and validated Use Case Documents.

Education

Bachelors - Business Administration

Skills

  • AGILE/Scrum
  • Requirements gathering
  • System analysis and gap analysis
  • Business process modeling
  • Process Optimization
  • System Integration
  • Change management
  • Project management
  • Stakeholder engagement
  • Test case development
  • Data analysis
  • Relational Database/SQL
  • Process optimization
  • Data mapping and modeling
  • Data migration and extraction
  • ETL knowledge

Certification

Google Project Management: Professional Certificate.

Tools and Software

  • Microsoft Excel
  • Power BI
  • MS Visio
  • JIRA
  • Azure Devops
  • Teradata
  • Datastage - ETL
  • UltraEdit
  • SqlDbx
  • Confluence
  • Sharepoint
  • Facets

References

References available upon request.

Timeline

Sr. Business Systems Analyst/Product Owner

Centene Corporation
03.2022 - Current

Solution Designer

Blue Cross Blue Shield
04.2021 - 10.2021

Sr. Business Systems Analyst

Centene Corporation
10.2017 - 11.2020

Business Systems/EDI Analyst

Coventry Health
03.2016 - 09.2017

Sr. Business Systems/EDI Analyst

United Health Group
07.2015 - 02.2016

Systems Analyst/ ICD10 Tester

Dignity Health
11.2014 - 06.2015

Bachelors - Business Administration

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