Girish

SUMMARY:
 12 years of professional experience in Healthcare (Medicaid, Medicare, Marketplace and Managed
Care), Finance and Marketing functional areas as a systems/policy analyst with expertise in Business
Consulting for various Healthcare systems and process Analysis, Provider Agreements, Federal
Regulations, Administrative Code, IT, Financial Modeling, System Integration roles, Interface
various file format exchanges, Marketing, Reporting, Pre/Post Production Implementations,
Presentations and Demos.
 2 years of academic learning, research and teaching Finance in areas such as but not limited to:
corporate finance, equity valuation (including analyzing strategies), revenue model, capital budgeting,
re-structuring, and risk management.
 Banking- Stock related Web Applications, Retail – pricing model web applications. Banking: stock
related web applications and retail pricing model web applications,
 Extensive knowledge in Medicaid/Medicare. Areas of expertise include: Claims processing
(Encounters/FFS), Pharmacy, Recipient (eligibility & enrollment), Provider, Prior Authorization,
Finance, EDI and Risk adjustment process (HEDIS and P4P metrics).
 Experience in Medicaid/Medicare – HIPAA EDI transactions (837 PID, 276/277, 270/271,835, 834 and
820) with Medicaid Management Information Systems (MMIS).
 Experience in monitoring regulations and 3-way contracts between Medicaid, Medicare and Managed
Care with external organizations such as CSSC, Palmetto/GBA and BCRC.
 Involved in Ohio Medicaid Mycare product design with CMS. Based on CMS guidelines for the State of
Ohio, Mycare product design includes enrollment, encounter claims, and the drug rebate process.
 Involved in various Managed care implementations for Molina Healthcare based on state regulations
upon procuring Managed care contracts for various health plans’ (Idaho, Mississippi, Ohio, New York,
Puerto Rico and Utah).
 Involved in supporting day to day operational activities in Claims (FFS/Encounters), Enrollment
(Change and Full file) for Molina Texas, Wisconsin and Illinois
 Worked with CMS/IRS for a successful implementation of 1095 - A project for 26 states in CY 2015.
 Worked with various external vendor organizations on various end to end projects such as:
o Health care excel (Prior Authorization validation),
o CGI (Claim recovery auditing)
o OAKS (Federal Financial reports on Medicaid Spending based on various fund codes)
o ODMH (Provider type 84 and 95 EDI implementation from MACSIS claims processing system
for 900 trading partners)
o ACS/Xerox (ODM pharmacy claims processing activities and drug rebate file processes)
o AHS (Managed Care Enrollment Center for state of OHIO-in handling 1061/1062 file
exchanges)
o Combined Provider Adjudication Order for Nursing facility providers and Title V and Title XIX
settlements for Hospitals
o HMS- Cost recovery activities for other insurance payment.
o OHIO Benefits/Ohio Integrate Eligibility system- Real time enrollment interface file layout
requirements with Accenture
o Worked with IRS for successful implementation of 1095-A project
o Worked with GHI vendor for successful implementation of claim adjudication process of Xover
claims.
o Worked with Price Waterhouse Coopers (PWC) Newborn End to End process design for OH.
o Worked with Health Services Advisory Group (HSAG) in various process auditing controls from
Molina perspective.
o Worked with Milliman in rate survey developed for Managed Care members for 3 state fiscal
years (2014-2017)
o Worked with Molina vendors for process improvements through National Delegated Contracts
(March Vision, CVS, SCION, Denta Quest, Delta Dental, Secure and Logisticare,IPA)
o Worked with PFK/HNCC on sub-capitated contracts for Molina OH.
 Worked with Medical Directors and external vendors for successful implementation of ICD 9 to ICD 10
conversion project until it is deployed in to production.
 Extensive experience in analyzing and providing/gathering requirements based on administrative code
defined by Human Health Services (DHHS) and writing business system functional specifications
including various business use cases.
 Excellent skills in developing and evaluating business process models.
 Ability to evaluate work flows by using process models.
 Advised leadership on improvement strategies, Competitive & Profitability Analysis.
 Proven ability to bridge business goals and technology by providing productive solutions.
 Effective communication skills for mediating between Management Teams, IT Group, Business
Group and Clients.
 Strong team building, conflict management, time management and meeting management skills.
  Proven success as a systems analyst through the years, providing a well-balanced understanding of
business relationships, requirements, and technical solutions for various domains like health
insurance, finance and banking. .
 Excellent analytical, methodical, and resourceful approach to problem solving.
 Ability to identify and concisely document root causes and corrective actions to meet short and long
term business and system requirements.
 Effective in executing multiple tasks and assignments ahead of schedule.
 Experience in creating and maintaining effective budgets with AVP of finance from each health plan and
also established Internal Process flow evaluation to see if everything is accurately implemented.
 Expertise in UML (class diagrams, object diagrams, GAP analysis, use case diagrams, state,
sequence, activity diagram, and collaboration diagrams) as a business analysis methodology for
application functionality designs using IBM’s Rational Rose.
 Excellent in developing and evaluating business process models.

EXPERIENCE

July 2015- Current

Healthcare Data Analyst
Molina Healthcare Inc of OHIO

 Working on various Insurance products that Molina Healthcare is participating in Ohio such as
Medicaid, Medicare, Marketplace, Mycare programs to meet the health care standards and the effective
compliance measures with provider agreements as defined by the Ohio Department of Medicaid, CMS
and Ohio Department of Health.
 Provide senior-level healthcare analysis for the state health plans, including quantification and analysis
of health care costs.
 Development and maintenance of databases, as well as other sources of information, for quality
initiatives, accreditation efforts, regulatory mandates and claim data coordination.
 Identified root cause of Encounter Claim rejections from the State and CMS. Addressed configuration
modifications necessary in QNXT based on root cause analysis, thus alleviating future State rejections.
 Implemented various QNXT edits based on healthcare standards to ensure accuracy in claim
adjudication based on provider claim billing.
 Reconciled pharmacy (CVS), dental (DentaQuest/Scion) and transportation (Logisticare/Secure)
vendor invoices to encounter claims submitted to the State of Ohio.
 Involved in QNXT system architect designs involving various health care modules (Inbound and
Outbound systems) for multiple State implementations of Molina such as New Mexico, Puerto Rico and
Florida.
 Involved in budget sessions for the calendar year 2016 for various profit initiatives created for different
health care models hence providing effective healthcare to member that are enrolled with Molina.
Assisted with research, development and completion of projects as requested by various internal
departments that supported requests from regulatory agencies, contracting agencies, or other external
organizations.
 Responsible for timely completion of projects including timeline development, maintenance,
coordination of activities and data collection Participated in workgroup meetings to resolve internal and
external edits that are posted on Encounter Claims.
 Resolved claim related issues that are posted with threshold edits and provided education material to
providers in order to remediate future billing issues.
 Evaluated and mitigated the high cost member related issues based on the line of business.
 Submitted the cost report cubes to ODM for financial, Members, Claims cubes for each quarter.
 Working closely with Risk adjustment team/HEDIS team to provide support with Altegra file exchanges
and Provider targeting for accurate claim billing.
 Working closely with provider data on various metrics that are part of the state provider agreement.
 Performed various Claims auditing to determine if they are accurately billed as per healthcare
guidelines.
 Performed complete enrollment reconciliation for 3 years and identified New Born errors, invalid Line of
Business assignment, Duplicate enrollments for members (which results in over payment for vendors)
and Recipient Linking issues
 Developed following system end to end processes to assist day to day activities of AVP of Finance and
Business users to monitor external/internal vendors-
o Invoice file reconciliation with claims that are accepted in Molina system
o Charge back files (if Invoice is paid but there is no sub-sequent claim associated with it in 35
days claim will go back on charge back file)
o Member Enrollment reconciliation files (Daily and Monthly)
o New born temporary reconciliation process
o Capitation payment reports
 Per member per month utilization trends based on various KPI variables such as provider and member
score cards and county/region
  Worked on various claim auditing reports that facilitated cost savings from a financial perspective and
provided training to business users on how to utilize these reports. These reports include:
o Retro enrollment changes impacting claims adjudication (Copay, Coinsurance, Member
Deductible, COB enrollment, Retro -Adds, Retro- Terms and Retro-changes)
o Duplicate claim report (Professional, Institutional, Dental)
o Nursing Facility Claims (Covered days, Non Covered Days, Coinsurance, Member Waiver
Program)
o Interim Claim billing
o Provider contract validations and creating ROI models based on new contracts.
o New born T01 reconciliation
o Risk Adjustment
o HEDIS reports related to Pre-Natal, Postpartum, Delivery
o Adolescent Wellcare
o Claim Advances
o Claim Interests and Penalties
 Provided various business requirements to developers and Developed reports to monitor performance
based on Finance KPI, Member utilization-
o CAP Claim Leakage
o CAP Trend Report
o PCP monitoring
o Vendor On boarding Process End to End
 Worked on modifying Molina signed provider agreements. Worked with government contracts and
associated business users to develop reports that illustrate Molina compliance for all metrics expected
by the State/CMS.
o Cost Reports
o MCR- Medical Cost Ratio
o Member/Provider Face to Face Forms
o Prior Authorization Turnover Rate
o Encounter claim utilization reports per 1000 member on different claim types
 Involved in scheduling Face 2 Face visits using CCA (Trizetto) and CMET Tools to better assist Molina
Medicaid members to get better transition of care model or discharge planning or Member outreach.
 Worked with Altegra in developing Risk Adjustment product for Molina states that involves:
o Payment structure for product
o Claim and Enrollment file exchanges for Molina states and Altegra
o Member, Provider Outreach structures
o Chart Data loading to correct Diagnosis codes based on chart data that is written by provider
with assistance of Clinical coders.
 Worked with HEDIS and P4P incentive team to develop incentive models for following measures:
o Delivery (Pre-Natal, Postpartum and High risk cases such as Low Birth Weight)
o Transition of Care Model (TOC) to reduce re-admissions
o AWC (Adolescent well Care)
o Vaccination programs for Flu and Pneumonia
o Early Periodic Screening Diagnosis Treatment (EPSDT)
o Nursing Facility Program Metrics (MDS)
o Integrated Risk Adjustment team with the HEDIS/P4P team to create a single point of
communication point for Providers and Members.
 Worked with CVS, where in Managed Care 25% of Medical spending in pharmacy claims. Developed
various standards involving-25% of Managed Care Medical spending is in Pharmacy Claims, hence
worked with CVS to develop various standards involving:
o Specialty Drug spending
o OTC spending
o HEP-C spending
o Opioid consumption monitoring
o Member Drug hindrance monitoring program
o 340B and Drug rebate program
 Developed various claim pricers that cannot be priced through QNXT- Developed mechanisms to price
claims that cannot be priced through QNXT.
o EAPG implementations with Optum
o Home Health Claim pricing
o NDC claim pricing for Medical Claims
o APR-DRG claim pricing
o Shadow pricing for Capitated Claims to create ROI metrics to monitor CAP contracts

Environment: QNXT, CCA, CMET Microsoft SQL server, Microsoft SQL, SharePoint,SSRS,SSIS
Mar 2015- July 2015
EDI Solutions Analyst
CMS/IRS- Cognizant
 1095-A is the tax statement that the Health Insurance Marketplace sends to Americans (beginning in 2015)
who were covered by a qualified health plan (QHP), for any period, during the previous year through either
the Federally Facilitated Marketplace (FFM) or a State-Based Marketplace (SBM). Involved in researching
the customer outreach team on the various systems for the open cases by recipients by following up with
issuers (834, 820), FFM (HIC, Flat file, pipe delimited file).
 Provided day-to-day guidance for the assigned team members (36 member team) on the enrollment
reconciliation team Provided day to day guidance to the enrollment reconciliation team (36 team
members).
 Completed 1095-A tax reconciliation casework for various states (Palmetto and Cahaba Jurisdiction).
 Resolved enrollment issues for policy start and end dates, APTC, SLCSP premium amounts.
 Worked with IRS, CMS and Insurance vendor file exchanges for data accuracy for tax process.
 Participated in testing and documentation of issues, case analysis documentation.
 Worked with the technical and development team to resolve identified issues in a timely manner.
 Reviewed documented training material for accuracy and assist in end user training and support

Environment: Share point, Claims, Excel, Mainframe, .Net applications, VB Script, SQL.

Dec 2010- Feb 2015

Business Systems Analyst
Ohio Department of Medicaid, Columbus Ohio
 System Migration from legacy mainframe to MITS architecture model
MITS (Medicaid Information Technology System) which is federal mandatory regulation for replacing
the legacy system and will be replacing the 20+ Medicaid Management Information System (MMIS) for
claims processing. Involved in end to end migration of data, interface designs, batch jobs, data
modules, data schemas, end to end testing with external agencies, and maintaining 260 inbound and
outbound interface directories landing pads.
 Sybase hardware to HP_UX hardware migration
Hardware migration of servers, worked with network engineers in ping/Stub testing for TIBCO, FTP,
SFTP, Real time interfaces, external vendors logins and connections.
 5010 Implementation
Ohio Department of Medicaid implemented 5010 EDI transaction sets to be accepted from Trading
Partner communities, Providers, Clearing Houses, Vendors of Pharmacy, MCP’s and sister agencies
which is robust and wide variety data elements can be accommodated. I was Involved in complete end
to end project management of 4010 code set to 5010 code set migration. I would change this sentence
to something like: Involved with end to end project management of 4010 code set migration to 5010
code set when Ohio Department of Medicaid implemented 5010 EDI transaction sets to be accepted
from Trading Partner communities, Providers, Clearing Houses, Vendors of Pharmacy, MCP’s and
sister agencies which is robust and wide variety data elements can be accommodated
 ICD 10 Implementation
Ohio Department of Medicaid implemented ICD 10 code sets in 2014. ICD-10 offers a number of
benefits to Ohio Medicaid, some of which include- Enhanced code specificity, Improved ability to
measure the quality of health care services, Enhanced accuracy of data analytics and reporting,
Improved processes to identify fraud and abuse, Improved ability to identify populations and members
for targeted outreach and case management. I was Involved in complete end to end project
management of ICD-10. Would change this sentence to something like: Involved in end to end project
management of implementing ICD-10 code sets in 2014 when Ohio Department of Medicaid
implemented ICD-10 offering a number of benefits to Ohio Medicaid, some of which include- Enhanced
code specificity, Improved ability to measure the quality of health care services, Enhanced accuracy of
data analytics and reporting, Improved processes to identify fraud and abuse, Improved ability to
identify populations and members for targeted outreach and case management

 Mycare Ohio- Integrated program with CMS and managed care plans
MyCare Ohio is a system of managed care plans selected to coordinate the physical, behavioral and
long-term care services for individuals over the age of 18 who are dually eligible for both Medicaid and
Medicare. I was involved in Complete system designing, Encounter testing (837 P, I, D), Pharmacy
claims testing (NCPDP), documenting of Companion guides and Business Intelligence Analytical
Reporting. Involved in complete system design, encounter testing (837 P,I,D), Pharmacy testing
(NCPDP) companion Guide documentation and business intelligence analytical reporting for MyCare
Ohio. MyCare Ohio is a system of managed care plans selected to coordinate the physical, behavioral
and long-term care services for individuals over the age of 18 who are dually eligible for both Medicaid
and Medicare.

 CMS 416- Annual Early and Periodic Screening, Diagnostic, and Treatment of EPSDT Participation
 The annual EPSDT report (form CMS-416) provides basic information on participation in the Medicaid
child health program. The information is used to assess the effectiveness of state EPSDT programs in
terms of the number of individuals under the age of 21 (by age group and basis of Medicaid eligibility)
who are provided child health screening services, referred for corrective treatment, and receiving dental
services. I was I involved in various CMS related projects of Fee For Service (FFS) and Encounter
claims so that the said data will appear in the CMS reports (Example: CMS-64, CMS-372, CMS-416)

 Involved in 26 releases for MITS which is deployed to production for every 90 days. Worked on sub-
systems of healthcare and delivered and monitored best cost saving solutions for Medicaid in
collaboration with Medicaid Policy/Fiscal Agencies.

 ODM is migrating from an MMIS (20+) legacy system to MITS system which is developed by HP.
Working on various subsystems work flows and process flows.
 Sub systems involved Encounters, Managed care Pharmacy, Finance, MCP, EDI. Designing the file
layouts associated with the sub system and Third party involved in the file exchanges
 Validated the file layouts based on the requirements.
 Generated various reports and letters involved in the sub systems. Validated reports and Letters by
using SAP business objects.
 Involved in Trading Partner (Around 895 TP’s) testing for the translator maps which are designed for
the new system MITS.
 Involved in the Encounter testing with 6 MCP’s, for the Mycare program/ encounter edit Threshold for
the claims acceptance, Delivery payment and Edit testing.
 Reviewed EDI test requirements and developed test plans, physical mapping, communication protocol
setups and application support.
 Performed code translation maps for ICD-10 changes and worked on ICD-10 code changes with
provider community.
 Testing on EDI 4010. Doing the GAP Analysis for the transition to EDI 5010, Developing project plan &
Test plan for 5010 transition. Tested EDI 4010. Conducted GAP analysis for the transition to EDI 5010.
Developed the project plan and test plan for this transition.
 Developed EDI X12 based implementation guides and ODM’s application file formats.
 Developed logical mapping for new trading partners, developed cross references, and storing of
inbound and outbound data files.
 Experienced in conducting User Acceptance Testing and also performing testing with trading partners
to accomplish project deadlines.
 Extensively worked on Managed care plans (MCP), actively involved in the file exchanges of MITA
architecture.
 Verified Inbound and Outbound file layouts from MITS to various sources.
 Designed the logic associated with the unsolicited report indicating acceptance or rejection of claims in
adjudication (U277).
 Performed 4010 X12 analyses, resolving various compliance issues which were causing Translator
failure of X12 and thus resulting generation TRC’s and rejected 997’s.
 Worked closely with trading partner and MCP’s in identified potential Edit testing and compliance
testing.
 Attended daily Failure Analysis Review Meetings which prioritized the severity of Defects.
 Utilized the 5010 GAP analysis documents to write test cases associated with deployment of various
releases
 Worked on EDI response file analysis of Pharmacy (NCPDP) Claims.
 Adjusted recipient eligibility spans based on the 7120 form which is submitted by the caseworker in the
Buy-In Medicare, in the eligibility systems like CRIS-E, SACWIS and in the MITS eligibility panels.
 Strong understanding of Data Warehouse concepts, OLAP, Star Schema, Data Modeling using
Normalization, Business Process Analysis, Dimensional Data Modeling, Fact & Dimensions tables,
Physical & Logical Data Modeling & ER diagrams. Proficient in SQL, PL/SQL, Views, Indexes, Stored
Procedures, packages, database triggers, exception handlers, Cursors other components of database
applications.
 Worked extensively with Business Objects report functionality like Breaks, Alerts, Filters, Sorts, Query
Prompts and Drill filters.
 Worked on the various CMS projects that are mandated for State Medicaid agencies like CMS-416
report, 1% FFP increase, CMS-64 reports, financial reports, and various other fund code related
reports.
 Created Business objects reports for business based on needs from various universes like prior Auth,
Claims, Managed care and Finance.

Environment: .NET application, Quality Center 9.2, Apollo Data repository, EDIFECS, SQL, Notepad++.
Iterative SDLC, SAP Business Objects
Jan 2010 – Nov 2010
Business Systems Analyst
Department of Human Health Services, Lincoln, NE
State of Nebraska uses Agile Methodology for MMIS which is a legacy system, various Service Change
Requests which are part of CMS services.
 Under general direction involved in gathering, defining and documenting highly complex business
requirements for SCR’s from the SME’s.
 Facilitated meeting discussions between business users, Lead Business Analyst and Technical
Analysts.
 Documented organization policies and procedures in the context of system requirements.
 Worked with technical staff and business users to achieve the best problem solving methods and
workable solutions.
 Performed feasibility services and gap analysis in the system, by understanding the As-Is system in
order to develop a better To-Be system.
 Performed data analysis, data mapping, data validation and reconciliation. Designed various data file
layouts to exchange between third parties.
 Created test plans, test scripts, test cases based on the requirements to cover the requirements with
minimum number of test cases.
 Ensured testing results correspond to the business users expectations.
 Worked with Business leads, Stake holders, and Technical staff to identify key measurable values to
track and manage the project issues.
 Created user manuals for the end users, provided support for the client who includes training and help
instruction.
 Worked on the monthly and quarterly updates for the various Reference panels which are received from
the CMS.
 Worked on the Medical Home Pilot project which provides the patient centered medical home, it mainly
consists of patient and doctor relation to make better health condition.
 Worked on a project which removes caseworkers, replacing them with the Document management
centers and IVR systems.
 Worked on NDC crosswalk with HCPCS codes.Designed file layouts for Mental Health Substance
Abuse (MHSA) for the Managed Care Plans.
 Performed various data analysis for the various claim types, major subset mainly comprises of
Professional, Institutional, Dental and Crossover claims.
Environment: Mainframe, Lotus notes, Excel, SQL Server, Clarity.
Oct 2007- Jan 2009
Teaching Assistant
New York University, NY
 Teaching assistant for advance corporate finance for under graduates at NYU.
 Teaching assistant for MS Excel and VBA classes to graduate and under graduate students at NYU.
 Emphasis on data analytics and data mining using SAP and excel with solver, pivot-tables, vlook-up and
other essentials.
 Worked on financial modeling and data analytics research project to access comprehensive models in
index formation by data mining and statistical analysis of weights of each parameter involved in modeling.
 Involved in academic advising and counseling for new and current students for Financial Engineering
program.
 Lead a team of 4 to analyze quarterly revenue reports for graduate admission, and provided strategic
planning, forecasting and budgeting to improve business process for following academic years.
 Managed projects and operations for recruiting new students and consulting companies overseas;
promoted academic programs and administration in education fairs domestically and internationally.
 Extensive research and gather statistics for new strategies and weekly reporting of team’s progress.

Oct 2005 – July 2007

Business Analyst,
Abhibus Ltd, Hyderabad, India
 Worked closely with Co-founder from drafting the business action plan to implementation including
acquiring permissions and licenses from various departments.
 Worked on research reports involving profiling of financial and operational aspects.
 Worked in the E-business analysis department over various e-commerce websites
 Provided solutions to clients on feasibility and effort minimization in execution of their operations
 Performed Statistical and data analysis and extensively involved in writing SQL queries
 Analyzed the market segments and potentially involved in marker penetration strategies.

ACADEMIC PROJECTS
 Immunized Bond portfolio against unexpected interest rates fluctuations using asset-liability duration
matching (Risk Management).
 Implemented Black-Scholes and Binomial Option pricing models and performed sensitivity analysis
using underlying asset price and volatility.
 Estimated Term Structure of Implied Volatility: Fitting various models for the implied volatility for
European call options by minimizing the error between the Black-Scholes price and the actual traded price.
 Performed Stock portfolio optimization in MS Excel (VBA) using Black – Litterman approach
 Simulated single period models, multi-period models, option-pricing and hedging, Risk Neutral Pricing in
Matlab.
 Oil and Gas Derivatives: Worked on various types of derivatives like futures, options, swaps, their hedging
strategies, closely followed NYMEX and Department of Energy reports.
 Econometric analysis on S&P and CAC 40 index: Used sophisticated econometric techniques along with
time series regression to measure correlation, interdependence between the two markets.
 Performed Trend analysis on Gold: performed Time series analysis of Gold market of India by using
Linear Trend, Seasonality, Cyclicality and irregularity.

COMPUTER SKILLS
Software languages : C, C++, Java, SQL, Ruby script, Gherkins, XML
Application Packages : Microsoft Excel, VBA, MATLAB, HP Quality center, Lotus Notes, E-views, OBIEE,
Visio, SAP Business Objects, SSIS, SSRS
Databases : MS SQL Server, MS Access
Operating Systems : Windows, UNIX, Linux, Mainframes

CERTIFICATIONS AND ACHIEVEMENTS

 Recipient of the prestigious Pratibha Scholarship (2002, 2003, 2004, 2005 and 2006) from
Government of Andhra Pradesh for being in top 0.01% in the State board examinations.
 Received award for obtaining 100% marks in Mathematics, Physics and Chemistry in high school
examinations for 5 years.
 General Secretary, Pharmacy Association for year 2003-04,
 Editor of the “DROGUE” magazine in BITS-Pilani for 2004-2005.
 Summer internships in Central Drug Research Institute Lucknow (2004-2005) as a pharmaceutical
anlayst
 Junior research intern, in analyzing the paper quality for Sirpur paper mills ltd (2002-2003).
 Co-authored a research paper ‘Wound healing property of Momordica Charantia L fruit powder’
published in International Journal of Herbal Pharmacotherapy in CDRI.

EDUCATION
2007-2009 Master of Science in Finance Risk Engineering from Newyork University (NYU).
2001-2005 Bachelors of Pharmacy (honors) from Birla Institute of Technology & Science (BITS), Pilani,
India.