Pradeep Kumar Nethi
Summary
With over 10 years of specialized experience in the U.S. healthcare industry, I have developed a strong background in payment integrity and fraud prevention , focusing on the identification and management of fraudulent provider claims. Additionally, I have expertise in Coordination of Benefits (COB) to ensure that claims are paid appropriately and efficiently, minimizing errors and reducing the risk of overpayments or underpayments.
Overview
13
13
years of professional experience
Work History
Lead Business System Analyst
Carelon Global Solutions
Hyderabad, India
09.2021 - Current
- Supporting as System Analyst for Inventory and queue optimization system for Member’s Other health Insurance
- Working autonomously on small to large-sized features including planning, requirements management, elicitation, and analysis
- Teamed up with engineering teams on defining technical feasibility and realistic scope of each feature prior to program increment planning sessions
- Conducted PI breakout sessions and refinements with Dev and QA teams to make sure requirements and expectations are understood and clarified
- Worked in partnership with cross functional teams to implement a high-quality product that meets business requirements
- Worked closely with business to identify the requirements and key features required for implementation on the Pega application
- Managed backlog prioritization ensuring it is aligned with Release timeline
- Created Process flow charts & mockup’s using balsamiq in Confluence and writing detailed Acceptance criteria in user stories for Feature EPIC’s
- Integrated multiple Up & down stream systems using API’s and micro services
- Captured User role based Dashboard views, Work baskets and worklist requirements to identify the work assigned
- Created Swagger Document, Source to Target Mappings for API’s and validated them using SOAP UI and Power BI Dashboards
- Defined A base flow for Automating Primacy determination of a member with very limited user review
- Created Mapping and transformation documents to display raw data on a case for user verification
Sr Business System Analyst / Technical Analyst
Optum
Maryland Heights, Missouri USA & Hyderabad India
02.2012 - 09.2021
- Working on Retrospective side of the project to report fraud claims
- This includes new Algorithm development or enhancing the existing
- Interpreted and executed requirements, functional specifications and technical design documents for incoming projects (Rule) and communicate these effectively to the team
- Part of an Agile team working with business stakeholders, product owners, Developers to gather requirements to implement an algorithm in SAS
- Responsible for Designing and writing data specifications and experience using MS-Visio for process Modelling, Business process flow diagrams
- Created Technical Requirements Document (TRD) and User Test Plan (UTP) and Customer Acceptance Test Plan (CAT) based on business requirements
- Using UNIX environment, files were managed and jobs were kicked manually
- Performed data validations, unit, system and regression testing for SAS programs to meet high quality objective and used SQL queries for Output validation
- Conducted data extraction from many different database platforms and review, created Mapping document, analyze, and present information to ensure expected results
- Performed validation on SAS datasets Using SAS EG
- Extensively worked on extraction of data from databases using SAS SQL by creating SAS data sets
Education
Bachelors of Engineering - Computer Science
Bharat Institute of Engineering and Technology
Masters - Information Assurance
Wilmington University
12.2015
Skills
- Pega workflow
- Process flow
- Work flow
- Automation
- REsT API
- Wireframes
- ETL
- Data Integration
- US Health care
- Data Mapping
- Data Analysis
- Json
- Confluence
- SQL
- API Integration
Professional Experience Summary
- Working as Lead Business System Analyst in Carelon Global Solutions – Hyderabad From Sept'2021 to present.
- Worked as a Sr Business System Analyst in “Optum Hyderabad – A United Health Group Company” from Feb'2019 to Aug'2021
- Worked as a Technical Analyst in “ Optum USA – Maryland Heights , Missouri” From May'2016 to Jan'2019
- Worked as a Data Analyst in “Optum Hyderabad– A United Health Group Company” from Feb' 2012– April 2014
Timeline
Lead Business System Analyst
Carelon Global Solutions
09.2021 - Current
Sr Business System Analyst / Technical Analyst
Optum
02.2012 - 09.2021
Masters - Information Assurance
Wilmington University
Bachelors of Engineering - Computer Science
Bharat Institute of Engineering and Technology