Praveen Kumar

9+ years of healthcare EDI implementation experience across the full lifecycle: requirements gathering, analysis, mapping design, development, testing, go-live, and post-production support of HIPAA EDI applications. Manage trading partner onboarding and EDI implementations end to end, including new map development, companion guide changes, standards and translator upgrades, EDI re-certification testing, go-live, and 24x7 production support. Track implementation milestones, dependencies, risks, and status updates, and prepare implementation readiness and go-live checklists to obtain partner and business sign-off before production.

Gather and document business, technical, and operational requirements with business stakeholders, trading partners, vendors (clearinghouses, enrollment vendors), and technical teams, authoring Business Requirement Documents (BRDs), functional specifications, and Visio process/workflow diagrams. Analyze companion guides, HIPAA Implementation Guides (TR3), file layouts, and source data to define mapping specifications, validations, transformations, and processing rules for X12 5010 transactions. Deep experience implementing and validating the full HIPAA X12 transaction set: 834 (Enrollment), 820 (Premium Payment), 837 (Institutional/Professional/Dental), 835 (Remittance Advice), 270/271 (Eligibility), 276/277 (Claim Status), 278 (Service Review), 999, TA1, and 277CA, including ICD-10 code set validation.

Hands-on expertise with Edifecs SpecBuilder, XEngine, XEServer, Edifecs Application Manager (EAM), and Transaction Manager (TM), including companion guide development for X12 5010 transactions. Create test plans and test cases from staging to production, build and validate 834 and 837 test files, and execute unit, integration, regression, and UAT cycles to validate results and confirm acceptance criteria are met before release. Coordinate client and trading partner testing, communicate findings, and work issues to resolution with programming, QA, and business teams through go-live.

Perform production data reconciliation and root-cause analysis on enrollment, claims, and file-transfer discrepancies using 999/TA1/277CA acknowledgments and SQL, driving corrective actions and process improvements. Configure SNIP level 1-7 validation rules in Edifecs to enforce syntax, HIPAA balancing, code set, and situational compliance, strengthening data quality controls on inbound EDI files. Extensive knowledge of FACETS (Benefit Enrollment, Claims, Provider, UM) and QNXT integration, ensuring accurate downstream processing of enrollment and claims data, with hands-on FACETS front-end and batch/membership testing.

Write SQL queries against Oracle and SQL Server (TOAD, SSMS) to validate data integrity, reconcile enrollment counts, and support audit and compliance reporting. Maintain implementation documentation, companion guides, mapping specifications, SOPs, decision logs, and runbooks, and provide knowledge transfer to operations and supp

Sr. EDI Analyst / Edifecs Developer (Healthcare) - L.A. Care Health Plan - CA

(2020-10)

• Lead EDI implementations for new transaction sets, trading partners, and companion guide changes with external trading partners, vendors, and internal business teams, from intake and onboarding through go-live and post-production stabilization.
• Track implementation milestones, dependencies, risks, and status updates, keeping business and technical stakeholders aligned on open issues through go-live.
• Gather requirements and build mapping and testing specifications aligned to HIPAA Implementation Guides (TR3), companion guides, and healthcare operating rules for X12 5010 transactions.
• Design, build, and maintain inbound/outbound 834, 820, 837 (I/P/D), 835, 270/271, 276/277, 278, 999, TA1, and 277CA transactions using Edifecs SpecBuilder and XEngine, defining mappings, validations, and transformations.
• Build and maintain routing rules and validation logic in Edifecs Application Manager (EAM) and Transaction Manager (TM) for 834, 820, and delimited flat-file transactions across trading partners.
• Configure SNIP level 1-7 validation rules in Edifecs to enforce syntactical, HIPAA balancing, code set, and situational compliance, strengthening data quality controls on inbound files.
• Partner with business analysts, QA, and infrastructure teams to clarify requirements, resolve implementation questions, and translate regulatory and business requirements into Edifecs map and configuration changes.
• Build and validate 834 and 837 test files, and develop and execute unit, integration, regression, and UAT test cycles for new and modified EDI maps, reconciling results before production release.
• Prepare implementation readiness and go-live checklists and obtain partner and business sign-off and implementation approvals before production deployment.
• Perform end-to-end testing and audit of 834 enrollment files, identifying discrepancies and driving root-cause resolution to keep enrollment processing within SLA.
• Monitor daily production file cycles using Edifecs TM, SQL diagnostics, and Dynatrace, proactively identifying transaction delays and failures before they affect SLA commitments.
• Analyze and resolve 837 claim rejections and 834 enrollment discrepancies using 999, TA1, and 277CA acknowledgments, improving first-pass acceptance rates and reducing manual rework.
• Perform production data reconciliation with SQL against Oracle and SQL Server to validate transaction data integrity, reconcile enrollment counts, and support audit and compliance reporting.
• Partner with Facets configuration and claims teams and support QNXT integration points to ensure accurate downstream processing of 834 enrollment and 837 claim data.
• Provide Tier 2/3 production support and issue triage for claims, eligibility, enrollment, and remittance transactions, coordinating resolution with DBAs, QA, and business teams in a 24x7 on-call rotation.
• Create and maintain implementation documentation, companion guides, SOPs, decision logs, and runbooks to support knowledge transfer and handoff to operations and support teams.
• Automate daily enrollment reporting, deployment tasks, and routine EDI operations with PowerShell and shell scripts, reducing manual intervention.
• Build Tableau dashboards that give business and operations stakeholders visibility into EDI transaction volumes, error trends, and SLA performance.
• Environment: EDIFECS 9.5/10.x, Edifecs SpecBuilder 8.0/9.2, XEngine, XEServer, EAM, Transaction Manager, Facets, QNXT, Oracle, SQL Server, T-SQL, SSMS, Healthcare Operating Rules, Dynatrace, Tableau, XML/XSLT, PowerShell, WinSCP, Putty, AWS, Windows Server.

Sr. EDI Developer / Integration Engineer - Kuehne & Nagel Inc. - Naugatuck, CT

(2018-10 - 2020-09)

• Managed the full onboarding lifecycle for new trading partners, including migration of trading partners to SAP IDOC.
• Authored Business Requirement Documents (BRDs) and functional specifications to capture trading partner and internal stakeholder requirements ahead of EDI map development.
• Created Visio process and workflow diagrams to document current-state and future-state EDI business processes for trading partner onboarding and internal system integrations.
• Performed root-cause analysis on recurring EDI transaction failures and map defects, identifying process gaps and driving corrective actions to reduce repeat issues.
• Led creation and execution of test plans for new and modified EDI maps, coordinating unit, integration, and customer acceptance testing cycles prior to production release.
• Designed, developed, and implemented 810, 820, 830, 832, 850, 852, 855, 856, 857, 864, 867, 875, 879, 880, 940, 943, 945 and 997 transaction sets.
• Developed maps to translate customer EDI to SAP IDOC and other custom flat file formats.
• Created maps for Purchase Orders (850), Advanced Ship Notices (856), Invoices (810), Application Advice (824), Inventory Inquiry (846), Text Message (864), Reports for Test Results (863), PO Change Req Acknowledgement (865), Purchase Order Acknowledge (855), and Order Status Inquiry/Response (869/870), 940, 943, 945 (Advice Transaction Set), 997 (

Master's - Computer Science - University of Illinois Springfield (2017-05)

Bachelor's - Computer Science Engineering - Jawaharlal Nehru Technological University, Hyderabad (2015)