Greater Richmond Region
Advisor‑level Business Systems Analyst and Business Architect with 19+ years of experience delivering complex, regulated healthcare solutions across payer, provider, PBM, and government programs, including Medicare and Medicaid. I bring deep expertise in claims and provider systems, PBM and pharmacy platforms, and enterprise data modernization, with a proven ability to translate regulatory and operational requirements into scalable, compliant technology solutions. Known for bridging business and technology, I partner closely with stakeholders and engineering teams to drive clarity, execution, and results. My background spans medical, dental, and pharmacy claims adjudication, NCPDP D.0 and F6, EDI (834/837/835), and large‑scale healthcare data integrations in highly regulated environments. I combine strategic leadership with hands‑on analytical depth, supporting informed decision‑making through SQL‑driven insights and strong delivery discipline across Agile and hybrid models. Core Expertise: Business Systems Analyst Advisor / Business Architect / Implementation manager Medicare & Medicaid (State FFS, ADAP), Enterprise Data Warehousing & Operational Databases Medical & Dental Claims Adjudication; EDI 837 / 835 / 834 / 820 / 27x Pharmacy Claims Adjudication; NCPDP D.0 & F6 Provider, Practitioner & Member Operations (Billing, Contracting, Credentialing) HIPAA, NCPDP, CPT, and Regulatory Compliance
•Serve as Lead Business Systems Analyst for State Medicaid FFS and ADAP implementations, ensuring compliance with regulatory, contractual, and enterprise requirements. •Lead end to end requirements elicitation, business process analysis, and solution definition for complex PBM workflows across eligibility, claims, formulary, provider, practitioner, and prior authorization domains. •Translate business, operational, and regulatory needs into user stories, interface specifications, data mappings, and process flows to support Agile and Waterfall delivery models. •Act as a primary liaison between clients, project managers, developers, QA, and operations, ensuring clear communication, alignment, and traceability throughout the SDLC. •Support solution architecture and interface design for inbound, outbound, conversion, and internal data exchanges, including EDI 834, EDI 837, NCPDP Batch D.0, and NCPDP Post Adjudication D.0/F6 formats. •Perform SQL based data analysis using Oracle, Redshift, and SQL Server to validate requirements, assess business impact, support defect triage, and ensure data integrity across PBM systems. •Lead and support UAT planning, execution, and go live readiness, including test scenario validation, defect analysis, root cause investigation, and coordination with business and technical teams. •Partner with program and project management to support estimation, dependency management, risk mitigation, and stakeholder communication across multiple concurrent initiatives. •Provide mentorship and functional leadership to junior analysts, improving documentation quality, PBM domain expertise, and adherence to SDLC best practices. •Support and enhance ETL and data integration solutions using SnapLogic, Informatica, and Oracle PL/SQL to ensure accurate and compliant data movement. •Contribute to operational stability through experience with file transfers (MoveIT), job scheduling (Tidal), and AWS cloud environments supporting PBM operations.
Part of Interfaces & Managed Services team responsible for data interfaces that bring data In and Out the company. •Lead Analyst/Implementation Manager for State Government FFS Medicaid and ADAP projects for Pharmacy Benefit Management System. •Function as primary contact for specific State clients assigned by Magellan leadership and function as a primary SME liaison between business BAs and IT project team. •Conducts research and analysis of any data pertaining to contract, clearly communicates findings to appropriate IT personnel, and translates data in a knowledgeable manner to the account team. •Conduct discovery sessions and manage user expectations and requirements scope. •As an analyst, ensure interface design requirements are identified, documented, and implemented to support new client implementations. •Lead requirements elicitation and definition. •Identify risks/issues & work with cross functional teams internally/externally for mitigation for the interface development and enhancements. •Document requirements and mapping document for Conversion, Outbound, Inbound, and Internal interfaces. •Experienced in writing new Snaplogic pipelines and applying minor fixes to Oracle PL/SQL (Stored Procedures/Packages). •Familiar with Enterprise Standards for Enrollment (EDI 834), Claims (EDI 837 versions, NCPDP Batch D0 claims load, NCPDP Post Adjudication versions like 4.2, 47 etc.), Prior Auth Load (SA 2.2) and Provider (NCPDP Service Provider load)& Practitioner Loads and mapping of converted Prior Authorizations, Claims History, Service Provider/Practitioner, Automated Prior Authorization Evaluation Criteria and Formulary Loads between Magellan and external parties. •Familiar with querying Oracle, Redshift and SQL Servers databases and activities like Tidal scheduling, setting up MoveIT transfers, AWS Cloud environments. Tools & Technologies used: •Requirements management/collaboration tools (e.g., JIRA) •Others: Toad, PowerCenter, UiPath, Snaplogic, Unix, AWS.
As member of IT Data Exchange team, develop business and technical requirements for different projects that provide extracts from Enterprise Data Warehouse to different groups based on requirements. Elicit, document and manage functional requirements. Act as a primary liaison between business users/BAs and AD/QA project team. Manage user expectations, changes to requirements and project scope. Responsibilities: • Lead development of functional requirements and design documentation, facilitates testing and training. • Gathers, reviews, analyzes, and evaluates user needs. Involved in planning BSA effort on the project. • Act as a primary SME liaison between business users/BA's and IT project team. • Manage user expectations and requirements scope. • Lead requirements elicitation and definition. • Participates in fit/gap analysis of functional requirements. • Facilitate functional requirements walkthroughs and respond to Test team ambiguity review questions. • Lead functional documentation design (use cases, functional specifications, reports, screen prototypes). • Review test cases. • Work closely with Project Manager, architects, developers, Test team, business users/BAs and applicable outside entities (vendors and others). • Contribute to development of user guides, reference manuals, training materials and code release artifacts as appropriate. • Actively participates in change management activities. • Works with Project Manager to ensure compliance to System Development Life Cycle (SDLC). • Provides estimates for BSA work efforts on new projects and for on-going forecasting. • Has ongoing interaction with senior management. • Performs related duties as assigned or requested. Tools & Technologies MS Office Suite: intermediate skills in Word, PowerPoint ,Excel, Access and Visio. Requirements management and collaboration tools (e.g. ReqPro,CQ,RDNG) Knowledge of database environments (DB2, Teradata, Big Data). Teradata SQL assistant, Informatica Data Explorer.
Worked for one of the largest health benefits companies in the United States - WellPoint (Department : Sales & Marketing). Responsibilities: • Coordinate the work of developers and coordinate the communication between onshore and offshore teams. • Review, analyze & create BRD's identified Functional Requirements & Non Functional Requirements using Rational Requisite Pro. • Working closely with the business to gather business requirements and formulate it into technical requirements. • Design technical solutions based on the technical requirements and business requirements. • Create Current Process Flow (as-is process) & Future Process Flow (to-be process) using MS Visio. • Daily task creation, allocation, tracking and metrics preparation, ensuring the optimum use of available resources. • Estimation of the effort for the task, so as to meet the Service Level Agreement and MTTR (Mean Time To Restore). • Ensure quality of deliverables by conducting reviews and establishing required standards. • Perform code changes, unit testing and support system testing (batch job run, defect fix). • Test case preparation and execution, Reporting bugs, Defect tracking and Documentation of test cases and results. Log defects using Rational Clear Quest & produce defect status reports to ensure quality standards. • Undertake total responsibility for the software development, testing activities and release of deliverables on the pre-decided date throughout the life of the project. Tools & Technologies Operating Systems Windows XP/Vista/7, MVS Z/OS Languages: COBOL, JCL, C, REXX Databases: IMS-DB, DB2, VSAM, Tablebase. OLTP CICS Tools & Utilities ISPF/PDF, TSO, Easytrieve (EzTrieve), Super-C, Changeman (CHGMAN), Endevor, IOF, SDSF, Control-M, SAR, Abend Aid, XPEDITOR, TRACK, FILEAID, IBM Debug Tool, IBM Fault Analyzer, IBM File Manager, SPUFI, QMF, OPTIM, IBM Rational Quality Manager, IBM ReQPro, ClearQuest, TSRM.
Worked for WellPoint (Department : WellPoint Dental Systems , Sales & Marketing area). Objective of this project is to provide consulting services to applications that are involved in renewals and maintaining online broker system. The scope includes analysis, enhancement and production support of existing systems. Responsible for the development of an information system. Design and modify systems by turning user requirements into a set of functional specifications.
I have been providing development and enhancement support for the US based insurance company WellPoint (Department : WellPoint Dental Systems). . I was part of a production support team called Dental LightsOn which takes care of the 24/7 production support and handles Queue(issue) work.
Acquired training in mainframe technologies - MVS, COBOL, CICS, JCL, and databases like DB2, VSAM. Java, RDBMS, Software Development. Started with WellPoint project.