Prashanthi Bojja

HIPAA-certified EDI claims analyst with over 6 years of experience in healthcare claims processing and healthcare technologies. Over 6 years of experience in Healthcare EDI claims processing, with extensive exposure to both Payer and Provider sides of the healthcare industry. Comprehensive experience in EDI transactions and claim processing systems.

In-depth knowledge of HIPAA EDI X12 transactions, including 837 (Institutional, Professional and Dental), 835 (ERAs), 276/277 (Claim Status), 834 (Enrollment), and 270/271 (Eligibility Request and Response). Extensive experience with CMS Medicare and Medicaid submissions, including custom edits for both 837I and 837P. Implemented system requirements by defining, analyzing, and resolving system issues, designing solutions, and establishing testing standards.

Strong knowledge of Edifecs applications such as SpecBuilder, (9.2) Transaction Management, Encounter Management (9.3), EAM, and performing Edifecs upgrades. Expertise in 270/271 eligibility and 276/277 claim status transactions and responses. Developed and implemented workflow solutions by evaluating system needs and proposing alternative approaches.

Collaborated with development teams to establish specifications, coordinate production activities, and ensure solution integrity. Validated program performance by conducting comprehensive functional and system testing. Extensively used SQL to retrieve and analyze claim and provider information.

Created and maintained system documentation to serve as a reference for users and technical teams. Significant experience in the Healthcare Payer industry, contributing to organizational objectives through information systems support. Proficient in identifying process gaps, developing process guidelines, implementing best practices, and creating standardized templates.

Designed, implemented, and documented test scripts, ensuring full functional test coverage. Trained end-users on effective application use, developed user manuals, and collaborated on system enhancements to improve functionality. Managed project documentation and collaboration through SharePoint, ensuring version control and team coordination.

EDI Support Analyst - Cigna Bamerk Insurance Agency

(2023-03)

As part of this project, involved in production support and generated day to day and weekly reports to meet the SLAs and submitted encounters to state and CMS. Identified potential issues and workarounds to make certain the encounter files are submitted and received on a weekly basis in a timely manner.

• Performed end-to-end data analysis for institutional, professional, and dental claims (837I, 837P, 837D).
• Validated encounter submission files through Edifecs SpecBuilder and EAM to ensure compliance with CMS/state specifications.
• Investigated EDI rejection and error reports, performed root cause analysis, and coordinate with IT and business teams for resolution.
• Run SQL queries to reconcile claim vs. encounter records and identify data discrepancies.
• Collaborated with state agencies to ensure accurate encounter resubmission and compliance with timelines.
• Supported automation of validation processes and creation of Power BI reports for encounter metrics.
• Supported production monitoring and error handling for recurring EDI validation issues in Edifecs.
• Conducted system testing and validation for new EDI implementations and partner onboarding.
• Collaborated with business stakeholders to perform root cause analysis of recurring EDI validation errors and implemented corrective measures.

EDI Production Support Claims Analyst - THP (The Health Plan), W Virginia

(2021-01 - 2023-02)

As part of Edifecs upgrade validated all EDI batch & real-time interfaces and coordinated with clearing houses, trading partners on missing ERAs. Extensively supported on missing claims.

• Demonstrated strong working knowledge of missing claims and provided detailed SNIP-level error analysis to trading partners for resolution.
• Experienced in identifying missing 835s and reprocessing ERAs in production environments to ensure accurate claim reconciliation.
• Developed and implemented workflow solutions by evaluating and optimizing alternative processes for efficiency and accuracy.
• Possesses strong knowledge of enrollment (834) transactions, including inbound and outbound validation.
• Validated HIPAA 5010A1 X12 standards, including 837 (I/P), 276/277, 270/271, 835, 278, 999, TA1, and 277CA transactions.
• Demonstrated strong expertise in Edifecs SpecBuilder, including data creation, data de-identification, data comparison, and guideline creation.
• Skilled in relaxing SNIP (1–5) level errors to ensure accurate and compliant EDI processing.
• Created and managed Agreements, Trade Relationships, and Partner configurations using Edifecs Transaction Management (TM).
• Analyzed X12 transaction files using both Edifecs Transaction Management and SpecBuilder to validate data accuracy and compliance.
• Validated internal and external trading partner as well as client-specific edits and guidelines to ensure compliance with organizational and industry standards.
• Experienced in creating test strategies, test plans, and test cases based on functional specifications to support system and integration testing.

EDI Claims Analyst - Gainwell Technologies, VA

(2020-01 - 2020-11)

As part of migration project, created test strategy and test scenarios and validated in downstream system all the interfaces.

• Defined application problems by collaborating with clients and evaluating existing procedures and processes.
• Developed effective solutions by preparing and evaluating alternative workflow options to improve operational efficiency.
• Controlled solution delivery by establishing specifications and coordinating with development teams to ensure successful implementation.
• Validated HIPAA 5010A1 X12 standards, including 837 (I/P), 276/277, and 270/271 transactions.
• Demonstrated strong working knowledge of Edifecs SpecBuilder, including data creation, data de-identification, data comparison, and guideline creation.
• Skilled in relaxing SNIP (1-5) level errors to ensure accurate EDI validation and compliance.
• Extensively worked on re-priced claims and ensured their accurate processing and validation.
• Analyzed X12 transaction files within Edifecs Transaction Management to ensure data integrity and compliance.
• Validated 835 Healthcare Claim Payment/Advice transactions for accuracy and compliance with payer standards.
• Validated 834 inbound and outbound (KPS) enrollment transactions to ensure proper member data transmission.
• Performed System Integration Testing (SIT), User Acceptance Testing (UAT), and Regression Testing to ensure high-quality system delivery.
• Validated 999 and TA1 implementation acknowledgment transactions to ensure EDI transmission accuracy.
• Created and managed change requests, technical specifications, program specifications, business scenarios, and use cases for process enhancements.
• Participated in technical specification reviews, code reviews, and design reviews with business users and development teams to ensure solution quality.

MCA - Masters in computer Applications - Osmania University

BSc - Bachelors in science - Osmania University