Pooja Nigam
Massachusetts
Summary
Senior Healthcare Data Analytics professional with 10+ years of experience in payment integrity, claims analytics, and data mining across Medicare, Medicaid, Medicare Advantage, and commercial healthcare programs. Strong expertise in translating CMS regulations, coding guidelines, reimbursement policies, and operational requirements into scalable audit and analytics solutions to identify improper payments and improve claims accuracy. Proven leader with experience managing and mentoring analysts, coordinating cross-functional teams, and delivering audit-ready, defensible outcomes.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Senior Business Data Analyst – Risk Adjustment
Blue Cross Blue Shield of Michigan
11.2023 - Current
- Lead analytics and data validation workflows supporting Medicare Advantage claims accuracy, payment integrity, and CMS submission readiness.
- Design and implement SQL-based data mining and audit logic in Databricks to identify claims inaccuracies, overpayments, and payment risks.
- Translate CMS regulations, coding guidelines, and reimbursement policies into scalable, repeatable analytics solutions.
- Analyze large-scale claims and encounter datasets to identify trends, gaps, and anomalies impacting payment accuracy.
- Review and quality-check IT-developed queries and outputs to ensure audit defensibility and alignment with business intent.
- Lead and mentor analysts and contractors, overseeing task prioritization, quality assurance, and delivery timelines.
- Partner with clinical, operations, compliance, and engineering teams to support audits, appeals, and remediation activities.
- Develop SOPs, documentation, and control artifacts to support audit readiness and consistent execution.
- Remote
Senior Business Data Analyst
Amtex Systems Inc. (W2 Contract)
07.2023 - 11.2023
- Supported Medicare claims and chart review analytics across multiple risk adjustment and CMS reporting workstreams.
- Prepared chase lists, performed gap analysis, and validated clinical documentation.
- Built dashboards and ad-hoc analyses using Databricks, SQL, and Tableau.
- Collaborated with operations and QA teams to improve encounter processing accuracy.
Business Analyst
Steward Health Care
02.2021 - 07.2023
- Led enterprise EDI initiatives and payer integrations supporting Medicare and Medicaid claims processing.
- Gathered and documented requirements for ACA-driven Medicaid enhancements and MMIS implementations.
- Executed UAT for healthcare applications and HL7 ADT interfaces.
- Directed HIPAA 4010 to 5010 upgrades across FACETS and QNXT platforms.
- Designed and executed system and user acceptance testing strategies; tracked and resolved defects.
- Built SQL-based analytical datasets supporting reconciliation, reporting, and compliance initiatives.
Business Analyst
Commonwealth Care Alliance
11.2019 - 01.2021
- Supported FACETS and QNXT enhancements for claims adjudication, enrollment, and provider workflows.
- Executed data migration, validation, and reconciliation across clinical and claims systems.
- Validated HIPAA EDI transactions including 837, 835, 834, and 270/271.
- Supported quality, performance, and regulatory reporting initiatives.
Business Analyst
Atlantic Health System
01.2016 - 10.2019
- Developed provider performance, quality, and HEDIS dashboards supporting clinical improvement programs.
- Led ICD-9 to ICD-10 transition analysis and regulatory compliance reporting.
- Performed complex SQL reporting and analytics for senior leadership and operational teams.
- Supported claims validation, process optimization, and compliance initiatives.
Education
Master of Business Administration (MBA) - Project Management
Sikkim Manipal University
IndiaBachelor of Commerce - undefined
Delhi University
IndiaSkills
Payment Integrity and Improper Payment Identification; Claims Auditing and Validation; Medicare Advantage, Medicare and Medicaid Claims; CMS Regulations and Coding Guidelines; Data Mining Ideation and Audit Logic Design; SQL, Databricks, Oracle, PL/SQL, Python; Tableau, Power BI, Excel; EDI X12 (837, 834, 835, 270/271); Cross-Functional Leadership; Team Mentoring; Vendor and Offshore Coordination
Certification
Effective Leadership: Master Management Styles – Coursera (2025)
Timeline
Senior Business Data Analyst – Risk Adjustment
Blue Cross Blue Shield of Michigan
11.2023 - Current
Senior Business Data Analyst
Amtex Systems Inc. (W2 Contract)
07.2023 - 11.2023
Business Analyst
Steward Health Care
02.2021 - 07.2023
Business Analyst
Commonwealth Care Alliance
11.2019 - 01.2021
Business Analyst
Atlantic Health System
01.2016 - 10.2019
Master of Business Administration (MBA) - Project Management
Sikkim Manipal University
Bachelor of Commerce - undefined
Delhi University