Config Analyst at Cigna (2023-06 – Present)
As part of the Cigna Healthcare initiative, the responsibility includes comprehensive configuration and validation of Benefit Plans, Member Hierarchy (Group/Class/Plan), Billing logic, and Provider Agreement setups using Facets, NetworX Suite. The project supports both Medicaid and Commercial lines of business, ensuring accurate claims, adjudication and compliance with regulatory requirements. The goal is to streamline the healthcare claims lifecycle by configuring benefits and provider pricing correctly so that member cost-share and provider reimbursements reflect the contractual terms.
Extensive work is performed in validating the Benefit Setup, Member Eligibility, Billing Structures, and Provider Contracts using SQL Server and related tools to drive high auto-adjudication rates and operational efficiency.
- Participated in client sessions to gather and analyze requirements for Benefits, Member Hierarchy, Billing, and NetworX Configuration.
- Designed and configured Benefit Packages, Billing Rules, and Provider Agreements (Fixed Fee, Case Rate, Per Diem, Fee Schedules) based on business rules and contract terms.
- Supported group/member premium configuration and ensured correct attachment of contracts and pricing rates using Pay Class and Pay Service mapping.
- Validated fields such as procedure codes in TPCT, SPCT, RCCT and SRCT tables, component, copay rules in SEPY Tables, coinsurance, deductible in ACCUM Tables, and reimbursement rates from NetworX, ensuring accurate cost-share for members and correct provider payments.
- Validating product shell using different Component IDs: PDDS (Product), PDPD (Business Information), PDBC
- Extensively worked on PCA Pends like PCAG Tables and make sure Everything aligned as per requirements.
- Created and validated Pay Class and Fee Schedule alignments to confirm contract terms match system logic and pricing outputs.
- Conducted SQL-based validations on benefit and provider configurations to support testing and resolve configuration discrepancies.
- Validated changes for Annual Renewal plans based on the Benefit as per the Member Plans.
- Support to cross-functional teams and led configuration activities for Medicare, PPO, EPO, and HMO plan types.
- Implementation of HIPPA 4010 to HIPPA 5010 expansion for EDI 834,837,835 file by Verifying routing and intermediate transformations, which takes place at ESB.
- Collaborated with business analysts and stakeholders to ensure clean configuration deployments and minimal impact on claims turnaround time.
- Worked extensively with sub-modules including Contracts, Benefit Plans, Members, and Claims, ensuring full traceability from configuration to claim outcome.
- Served as Configuration and Testing SME for Medicare, PPO, EPO, and HMO plans, with strong proficiency in configuring claim rules and pricing logic.
- Verified correct contract attachment to providers and pay classes, ensuring alignment with contractual pricing models such as fixed rates, case rates, and per diem structures.
- Created and validated Pay Classes and conducted pre-production testing to confirm contract and pricing rule integrity.
- Handshake with Quality Engineering, UAT, Business Partners right from Test design phase
- Publish a process flow in advance to Business for them to understand and get ready with claims outcome validation from the Baseline test results/reports
- Validation of Data Readiness for Data Migration / Provider, Member, Provider Prior Auth
- Review test objective & its outcome based on success criteria
- Align on Baseline claim volume and claims IDs based on objectives
- Loading 837 Files in the Preprod environment
- Lead the execution of Claims Processing in Preprod (including batch processing/troubleshooting)
- Publish test summary on claims load & associated outcome
- Conduct Defect Triage/Status Reporting
- Rerun Defects / Submit Clarifications
- Process mock claims in UAT, validate claims outcome, raise / track defects
Config/QA Analyst at Optum Healthcare (2020-05 – 2023-06)
- Fee Schedule Validation (MSOT)Master source of Truth vs Baseline (Claims processing working per the success criteria at the expected auto-adjudication rate)
- Handshake with Quality Engineering, UAT, Business Partners right from Test design phase
- Publish a process flow in advance to Business for them to understand and get ready with claims outcome validation from the Baseline test results/reports
- Validation of Data Readiness for Data Migration / Provider, Member, Provider Prior Auth
- Review test objective & its outcome based on success criteria
- Align on Baseline claim volume and claims IDs based on objectives
- Loading 837 Files in the Preprod environment
- Lead the execution of Claims Processing in Preprod (including batch processing/troubleshooting)
- Publish test summary on claims load & associated outcome
- Conduct Defect Triage/Status Reporting
- Rerun Defects / Submit Clarifications
- Process mock claims in UAT, validate claims outcome, raise / track defects
- Logging the defects in QTest and verifying all the cycles of the defect.
Config/QA Analyst at Barclays Insurance (2019-06 – 2020-05)
- Created high level strategy documentation and detailed test documents.
- Executed automated test cases and performed Back End Testing manually and Black box testing.
- Scripted the test cases for component and UAT using ALM/Quality Center.
- Logging the defects in Quality Center and verifying all the cycles of the defect.
- Performed UAT, Positive, Negative and Boundary testing using the approved test cases.
- Maintained strong relationships with developers which helped in better execution of test plan.
- Participated in regular meetings with developers for reviews and walkthroughs.
- Managed testing and created comprehensive testing scripts for a project involving the addition of new enhancements in Loan IQ.
- Create general regression scripts in Loan IQ for use in major software upgrades.
- Assisted in coordinating the consolidation of global testing across multiple projects.
- Performed Smoke testing, Security Testing.
