Overview
Work History
Education
Skills
Timeline
Generic

Sandeep Uprety

Dallas

Overview

9
9
years of professional experience

Work History

Sr. Technical Business System Analyst

Health Plan Services
03.2022 - Current
  • The project aims to enhance and streamline the delivery of healthcare services through the implementation of a comprehensive Case Management system
  • This system will enable the company to efficiently manage and coordinate patient care, ensuring optimal outcomes and improved patient experiences
  • Responsibilities:
  • Utilized Agile Methodologies to configure and develop process, standards, and procedures
  • Analyzed “TO BE” scenarios based on the data that are currently required to generate reports
  • Performed GAP analysis about membership management and claims processing to evaluate the adaptability of the new application with the existing process
  • Collaborated with healthcare professionals, case managers, and other stakeholders to identify and understand business needs related to case management
  • Worked with Business Process Modeling (BPM) - BPMN methodology
  • Created and updated Standard Operating Procedures (SOP) for enterprise-wide implementation project
  • Analyzed and documented the existing case management processes within the organization
  • Created 'AS-IS' and 'TO-BE' BPMN Visio business processes and data mapping to support user requirements
  • Involved in UML Modelling and Business process modelling and notations (BPMN) like Activity Diagrams, Sequence Diagrams, use case Diagrams, Process workflow Diagrams and created UI/UX wireframes in MS Visio and Mockup Screens
  • Used JIRA to create, maintain, and manage user stories
  • Collaborated with IT teams to ensure that case management systems are integrated seamlessly with other organizational systems
  • Read through Business Blueprints and other materials to gather information for creating the SOPs
  • Analyzed Service Requests and Change Requests available in JIRA and pertaining to everyday business need Analyzed Business Requirement Documents (BRD)
  • Designed business process flow diagrams and technical system diagrams for the stakeholders to understand the legacy, current and future state of the applications
  • Facilitated communication between different departments and teams involved in case management
  • Converted Business Requirements into Functional Requirements and System Requirements
  • Responsible for Documentation in each phase of Agile Methodology, Risk Assessment, and Validation & Verification process
  • Worked on PRD (project requirements documentation) to priorities the requirements as per business plan
  • Involved in analyzing the project scope as per PRD and finding “must be” and “would be nice” requirements
  • Documented all the changes for the enhancements and recommended changes for enhanced features of UI/UX
  • Worked on Microsoft Office (Outlook, Word, Excel, Visio, Access) at various phases of development for documenting the requirements
  • Evaluated and recommended suitable case management tools or software that align with the organization's needs and objectives
  • Used JIRA for test planning, maintaining test cases and test scripts, Defect Management and Defect tracking
  • Responsible for Data Profiling to determine data integrity for transformation of Data from Source to Target
  • Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins
  • Integrated various data sources with Multiple Relational Databases like Oracle, SQL Server, MS Access, and Flat Files
  • Arranged meetings & Managed meeting minutes & created Business process flows in BPM
  • Performed GAP analysis on claims processing to evaluate the adaptability of the new application with existing processes
  • Performed detailed business process assessment of the affected business areas
  • Created screen mockups and wireframes for prototypes for the front-end application of the products
  • Developed test plans and test cases to test the GUI and workflow for Quality Assurance
  • Worked on different EDI transactions like Claims (837), Premium Payment (820), Enrollment (834) and Eligibility (270) to send outbound files to external vendor
  • Define data requirements for case management, ensuring accurate and timely information flow
  • Developed and implemented EDI applications to process Health Care transactions as per the HIPAA implementation
  • Responsible for Data Profiling to determine data integrity for transformation of Data from Source to Target
  • Used MS Access for underlying database tables and resolving data issues.'
  • Created and maintained user stories using JIRA
  • Involved in developing and maintaining Test Matrix and Traceability Matrix and performing Gap Analysis
  • Developed, designed, & implemented department plan to configure new Facets integrated processing system, including workflow, management oversight, and performance analysis
  • Translated business requirements into functional specifications and documented the work processes and information flows of the organization
  • Participated in changes for system design, methods, procedures, policies, and workflows affecting Medicare/Medicaid claims to process in compliance with government compliance with processes like HIPAA/ EDI formats and accredited standards ANSI
  • Involved in identifying and studying the ACES and Facets system data and field-by-field analysis of the Facets system for attribute mapping purposes
  • Created different types of charts for Tableau dashboard analysis
  • Wrote business rules document, which documented the business rules across different systems
  • Participated in all phases of the Facets Extended Enterprise administrative system implementation, including planning, designing, building, validation, testing, and Go-live support phases
  • Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan
  • Responsible for unit testing and working with the System/Integration testing team in debugging/resolving any issues raised during testing
  • Created Data Flow Diagrams and Process flow diagrams for various load components like FTP Load, SQL Loader Load, ETL process, and other procedures requiring transformation
  • Used JIRA in executing the test cases, logging them, and directing it to the right team for any issue's encountered during the testing phase
  • Performed Requirements Management/Upload, Manual Testing, did Regression testing; SIT, UAT using JIRA
  • Created Project management plans for managing on time delivery using MS Project along with writing test cases, and systems integration test plans in JIRA
  • Involved in documentation of the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criterion for the requirements has been included in the UAT task plan
  • Environment: Agile Scrum, JIRA, SOP (Standard Operating Procedure), HIPAA, EDI, Facets, Case Management, ETL, Informatica Power Center, Medicaid, MS SQL Server, SOAP, Postman, REST API, SOA, Webservices, SQL, Tableau, MS SharePoint, Windows, XML, HTML, UAT.

Business / Systems Analyst

Alignment Healthcare
10.2019 - 01.2022
  • The project aims to enhance organizational efficiency and decision-making processes through the implementation of robust Business Analysis practices integrated with an effective Case Management system
  • The primary focus is on identifying, analyzing, and optimizing business processes while efficiently managing cases and incidents
  • Also, worked on Case management projects
  • Responsibilities:
  • Designed and developed project document templates based on SDLC: Agile-Scrum methodology
  • Administered and managed the design, development and implementation of Project Portfolio Management (PPM)
  • Identified opportunities for process optimization and automation within case management
  • Wrote User stories which included the business logic, expected behavior and user acceptance criteria
  • Involved in defect tracking management and used JIRA for requirements documentation
  • Created detailed documentation for case management processes, requirements, and system functionalities
  • Managed expectations and provided regular updates on the progress of case management initiatives
  • Worked on Business Intelligence standardization to create database layers with user friendly views in Teradata that can be used for development of various Tableau reports/ dashboards
  • Performed Back End Testing by executing SQL queries
  • Performed as-is analysis, to-be analysis, data Analysis, Gap analysis, competitive analysis, comparative analysis, process flows and business flows
  • Managed Project Portfolio, prepared Portfolio reporting metrics to all stakeholder and executive leadership
  • Developed, implemented and enhanced project portfolio metrics and reporting to capture weekly, monthly and accumulative trends
  • Gathered Requirement from the Client to fulfill the Application need for FACETS Implementation
  • Captured all HIPAA-related EDI data in the repository using FACETS
  • Creating and modifying Business Intelligence analytical reports using Tableau
  • Created 837(P, I, D) claims, and maintained data mapping documents about HIPAA transactions primarily 837(P, I, D), 834, 835, 270, and 271
  • Collaborated with testing teams to ensure that case management systems are thoroughly tested before implementation
  • Performing back-end testing using SQL queries to validate the data in the back-end SQL Server
  • Used HP ALM to log and address defects issues and for change management
  • Gathered requirements by conducting meetings with senior management team and coordinating JAD sessions, brainstorming and documenting requirements
  • Facilitated daily scrum, sprint planning and sprint retrospectives meeting
  • Elicited business requirements through interviews, document analysis, design workshops, surveys, use cases, and workflow analysis
  • Created comprehensive & feature-based Test Plans to test web-based mobile applications, as well as performing compatibility suites on numerous mobile devices
  • Participated in Sprint Planning, Daily Scrum Stand Up, and Sprint Retrospective meetings
  • Used SCRUM Related tools such as Rally to document and visualize stories, tasks and measure performance through burn down charts/velocity charts application
  • Designed business intelligence dashboard using Tableau Desktop and publishing the same on Tableau server, allowing executive management to view current and past performance sales trends, forecast sales, and to track existing customer sales
  • Accepted inbound transactions from multiple sources using FACETS
  • Extensively used SQL to retrieve data from the databases by writing Stored Procedures, views, triggers etc
  • Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics
  • Responsible for writing Business Use Cases, Business Rules, logical analysis and change management of requirements
  • Conducted Joint Application Development (JAD) sessions with IT groups
  • Identified the Key Changes and participated in Stakeholder Management to communicate effectively with them
  • Used Team Foundation Server (TFS) to open bugs, create tasks and user stories, initiate change requests
  • Used SOAPUI for web services validation for SOA architecture and RIT for Web application testing
  • Worked closely with business power users to create reports/dashboards using tableau desktop
  • Created Use Cases, Activity Diagrams and Activity Diagrams using MS –Visio
  • Created data set reports for users by writing SQL queries which then were used for UAT and defined data dictionaries for identified sources by working with data stewards and subject matter experts
  • Tested web, mobile applications and APIs in Agile process
  • Deployed SSRS reports and published Power BI dashboards to share them with the appropriate users
  • Attended Scrum meetings, which included Sprint Planning, Daily Scrums or Stand-ups, Sprint Check-In, Sprint Review & Retrospective
  • Utilize SQL server to run basic queries and obtain necessary data for Medicaid and Medicare Encounters
  • Worked with FACETS software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPAA transactions and facilitate the administration of HIPAA privacy rights
  • Conduct business area analysis and document requirements regarding user community's business intelligence needs
  • Created comprehensive & feature-based Test Plans to test web-based mobile applications, as well as performing compatibility suites on numerous mobile devices
  • Analyzed Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS)
  • Developed training materials and provided training sessions for end-users on new case management processes and systems
  • Facilitated meetings with the technical team and client team to analyze the current process and gather requirements for the proposed process
  • Monitor the performance of case management systems and processes
  • Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications
  • Daily and weekly status reporting to senior management
  • Environment: Agile (Scrum), HP ALM/QC, SQL, JIRA, EDI, FACETS, TFS, Tableau, UAT, Power BI, Case management, MS Office Suite (Word, Excel, PowerPoint, Visio, SharePoint, Project), Windows.

Business System Analyst

Centene Corp
06.2017 - 09.2019
  • The project was concerned with providing the ability to enroll new members through the Health Insurance Exchange (HIX) to comply with the Health Care Reform and obtaining business requirements from business users and stakeholders using interview sessions, brainstorming sessions, and personal interviews to get better understanding of the enrollment requirement changes from the Health Insurance Exchange (HIX)
  • It also dealt with Design, Development and Documentation of the ETL (Extract, Transformation and Load) strategy to populate the Data Warehouse from various source systems
  • Responsibilities:
  • Utilized Agile Methodologies to configure and develop process, standards and procedures
  • Analyzed “TO BE” scenarios based on the data that are currently required to generate reports
  • Wrote User Stories Elaborated User Stories and Acceptance Criteria, Reviewed user stories with team
  • Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents
  • Converted Business Requirements into Functional Requirements and System Requirements
  • Worked with project teams to integrate change management activities into the overall project plan
  • Documented the UAT Plan and worked with the UAT Team to ensure the acceptance criteria for every requirement has been included in the UAT task plan
  • Utilized JIRA to maximize traceability of all epics and User stories
  • Configured RRC to support agile themes, epics, features, user stories, success criteria and test case creation and traceability
  • Involved in project using SOAP UI and run request with input XML to receive a response XML for the request sent
  • Used the Data Warehousing Life Cycle to identify data elements from the source systems, performed data analysis to come up with data cleansing and integration rules for the ETL process
  • Supported project teams in integrating change management activities into their project plans
  • Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential
  • Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain an up-to-date list of payer contacts
  • Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other healthcare payers of government carriers
  • Worked with TriZetto based software called FACETS to obtain members information
  • Collaborated with IT Data Modeling team to ensure data model design is consistent and accurate with the business requirements
  • Created and managed user stories and Acceptance criteria in JIRA
  • Used JIRA for deploying task and Issue Tracking, User Story Management
  • Develop Mapping rules, design specifications and Use Cases for the HIPAA 834i/p/d; 820; 835, 824, 275 and others
  • Worked on multiple 837, 820 and multiple Eligibility (270/271) and healthcare claim status (276/277)
  • Create EOB systems (835)
  • Performed Web services testing in SOA (Service Oriented Architecture) using SOAP UI
  • Involved in data validation using web services testing with SOAP UI and validating request and response for XML, JSON files
  • Was responsible for configuring provider demographics, billing information and contract information in claim system while maintaining departmental quality and production goals and objectives
  • Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals
  • Gathered Requirement from the Client to fulfill the Application need for FACETS Implementation
  • Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/ Response), 834 (Enrollment/ Dis-enrollment to a health plan)
  • Worked on the claims related to Medicare (A, B, C, and D)
  • Responsible for creating data flow analysis and processes and creating management reports based on the analysis
  • Attended daily SCRUM sessions and guided developer regarding the defects, Technical Specification Documents and Mapping Documents
  • Developed dimensional model for Data Warehouse/OLAP applications by identifying required facts and dimensions
  • Created and executed Test Scripts in Excel
  • Responsible for cost estimation and timelines for various Business Intelligence reports using SSRS & Tableau
  • Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed, and issues were resolved beforehand
  • Integrated with other internal applications using SOAP and REST web services by generating the necessary stubs from the WSDL files for extracting the data from other applications
  • Worked with FACETS software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPAA transactions and facilitate the administration of HIPAA privacy rights
  • Analyzed Business Requirement Documents (BRD) and wrote User stories which included the business logic, expected behavior and user acceptance criteria
  • Environment: Agile/ Scrum, JIRA, SQL Server, HIPAA, EDI, MS Access, MS Excel, Facets, MS SharePoint, MS Visio, HTML, XML, SOAP UI, Web Services (SOAP, REST), MS Office.

Jr. Business Systems Analyst

Gold Coast Health Plan
02.2016 - 05.2017
  • E-care, a web-based technology uses databases to provide an extremely cost-effective tool to validate patient demographics and verify insurance eligibility in real-time conforming to HIPAA standards
  • The features of E-care include online appointments, Medicare/Medicaid Eligibility, Billing Verification, Self-Pay/Commercial Eligibility, Real Time Processing, EDI Migration, Billing Address Verification with Address History, and Insurance Eligibility Verification
  • Responsibilities:
  • Analyzed Service Requests and Change Requests available in JIRA and pertaining to everyday business need Analyzed Business Requirement Documents (BRD)
  • Worked on designing test scenarios, use cases, work breakdown structure using MS Project, interviewing and arranging resources, designing automation frameworks and setting up the performance test matrices
  • Identified, groomed and documented gap analysis in IT business processes to develop solutions in web/mobile applications within Sprint Planning the epic stories, user stories, use cases and tasks during UAT to enable code to be written without defects
  • Responsible for testing REST APIs and SOAP Services using Postman and SOAP UI
  • Support UAT testing and create defect guidelines documents for users using JIRA
  • Supported integrated EDI batch processing and real-time EDI using FACETS
  • Designed or presented conclusions gained from analyzing data using statistical tools like Microsoft Excel etc
  • Used HIPAA 5010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets
  • Created test cases and executed them in ready API
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Confidential Claims
  • Created and executed test cases using SQL queries to validate backend data and end-to-end data flow
  • Analyzed “TO BE” scenarios based on the data that are currently required to generate reports
  • Interoperability with all the types of message services
  • Validated sending and receiving HL7 messages
  • Extensively worked on Analyzing data, applying business rules, designing the data warehouse, creating data mart/ schemas, partitioning the data, creating easy/quickest ETL process to load the data and automating the ETL process
  • Set claim processing data for different Facets Module
  • Ensuring compliance with HIPAA (transaction sets 837,270,271,276 and 277) to ensure standardization of EDI transactions
  • Documented various key elements of HIPAA compliance and made sure that they were understood by the development teams and ensured that the test cases written for the project were HIPAA complaints
  • Incorporated Agile (Scrum) methodology to create User Stories and acceptance criteria
  • Developed Use case diagrams, sequence flow diagrams, swim lane workflows, class diagrams using MS Visio and UML concepts
  • Participated in developing and implementing End-End testing
  • Acted as a liaison between end user and Facets for user problems, outstanding issues, training needs and new software releases
  • Worked with SOAP UI to test cases with XML, WSDLS and web services
  • Build a communication and influence plan with Weekly and monthly reviews to help bring business partners and stakeholders along on the journey
  • Tested HIPAA Transactions and Code Sets Standards such as 837/835, 270/271, 276/277 transactions
  • Involved in Test Planning, Designing Test Cases and Scripts, Test Execution, Define and Track Quality Assurance Metrics such as Defects, Defect Counts, Test Results and Test Status
  • Performed back-end testing using SQL queries to validate data and perform Data integrity testing
  • Worked with Vendor Interface Program to load data from legacy system into temporary table on Excel to validate the data
  • Facilitated JAD session to find out the impacted area of functionality of Facets due to upgrade and cooperate with developer to come up with solution
  • Checked the data flow through the front end to backend and used SQL Queries to extract the data from database
  • Created the test cases and designed the test cases and performing calculations for results
  • Involved in Designing Test Lab and formulation of Test Strategy, Test Plans Performed functional testing to identify various critical points in the application
  • Delivered data and system analysis documentation that incorporates the business and data requirements including technical requirements
  • Participation in requirement / Use Case analysis, risk analysis and configuration management
  • Reviewed extensive SQL Queries with complex multi-table joins and nested queries
  • Ensured the accuracy and consistency of the data during the data loading process
  • Worked on HIPAA Code Sets Standards according to the test scenarios such as, 835 / 837 transactions
  • Performed Validation of XMLs through API Testing
  • Performed GAP Analysis to identify the segments and data elements of 5010 EDI transaction involved in the simulated claim processing system
  • Created conceptual diagram using Visio of the business process to find out the impacted area and to fix the problem
  • Provided the management with test metrics, reports, and schedules as necessary using MS Project and participated in design walkthroughs and meetings.

Education

Bachelor Of Computer Information Systems - Computer Information Systems

University of North Texas
Denton, TX
12.2021

Skills

  • Business process modeling
  • Data modeling
  • Use case development
  • Functional specifications
  • Software development life cycle
  • Agile expertise
  • Documentation
  • Research and analysis
  • Report writing
  • Production support
  • Program planning
  • Cross-functional collaboration
  • Teamwork
  • Teamwork and collaboration
  • Problem-solving
  • Time management
  • Attention to detail
  • Problem-solving abilities
  • Multitasking
  • Multitasking Abilities
  • Reliability
  • Excellent communication
  • Organizational skills
  • Team collaboration

Timeline

Sr. Technical Business System Analyst

Health Plan Services
03.2022 - Current

Business / Systems Analyst

Alignment Healthcare
10.2019 - 01.2022

Business System Analyst

Centene Corp
06.2017 - 09.2019

Jr. Business Systems Analyst

Gold Coast Health Plan
02.2016 - 05.2017

Bachelor Of Computer Information Systems - Computer Information Systems

University of North Texas

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Sandeep Uprety