Sonali Dixit

Experience

• 

  Electronic Data Systems

  Feb 2005 - Aug 2006

  Business Process Analyst

  EDS Inc. won the NewMMIS project for Commonwealth of Massachusetts. I was part of EDS application/business process specialist on MMIS application (Massachusetts Medicaid Information System). The project was expected to transform MMIS (legacy based system) to NewMMIS (Web based application) under HIPAA regulations. System caters the needs for Massachusetts State Medicaid customers and providers. Being a part of BPR (Business Process Re-engineering) team for NewMMIS, my main responsibility was to map 94 Legacy MMIS processes/system to NewMMIS processes/system to define any gap between two applications and document gap for NewMMIS design team and user training team. I achieved enormous success within short period of time with the BPR methodologies used for this project. Worked on all functional areas of NewMMIS including Buy-In Data Maintenance, Claims Adjudication and Pricing, Claims Payment, Claims Receipt, EPSDT, Eligibility Verification, Finance, General System, HIPAA Privacy, Interfaces, Managed Care, Member Management, Pre-Admission Screening, Prior Authorization, Referrals, Relationship Entity Management, Reporting, Security Management, Technical Architecture Vision and Third Party Liability. Completed the work-flows related to claims processing for providers, member data management, set provider specific rates, file formats mapping POPS, MA 21, APAS, and other related interfaces of NewMMIS. Kansas, Texas, Pennsylvania and Massachusetts based EDI (Interchange) systems (.Net and J2EE environment) was used as a reference to customize Commonwealth system, based on state regulations, HIPAA compliance, and product business rules. Show less

• 

  Blue Cross Blue Shiled of Illinois

  Sept 2006 - Mar 2008

  Sr. Business Process Analyst

  Health Care Service Corporation (HCSC) association was working on Federal mandated National Provider Identity (NPI) Compliancy project to help providers get their NPI before May 23rd 2008 and map it to their legacy Provider IDs and add the new NPI in all claims transactions that are related with Providers. The objective of having NPI helped improve the Medicare / Medicaid claims process more efficiently and conveniently than ever as all other legacy #, Provider IDs were being eliminated for a unique NPI. My responsibility was to analyze the business process and the changes the process to meet the needs for provider outreach program; to educate and coordinate the efforts between HCSC and the provider community team, to manage provider education materials of upcoming changes with new NPI regulation as per HIPAA regulation and documented End to end requirements to accept new CMS-1500 (08/05) revised versions & UB-04 with the new NPI field for the discontinuation of old CMS-1500 and UB-92 forms. Customized Blue Cross Blue Shield system of Illinois, New Mexico, Texas and Oklahoma, based on each state regulations, HIPAA compliance and product business rules. Worked on all informative web links those are associated with Blue Cross and Blue Shield (IL, TX, NM, & OK) to add the new feature – National Provider Identifier (NPI) and Reworked on all web content, Forms and Documents that have provider’s information, Legacy IDs, Medicare #s, Medicaid ID etc. to incorporate with NPI information to comply with HIPAA regulation for NPI. Create communication specification on how to and what messages needs to be sent out for new transition plan. Closely partnered with Business to Business (B2B) Clearing houses to work on problems and its solutions for claims submission to comply with the new NPI regulation. Worked closely with DCN Report, 30MI, and other batch processes to confirm that the NPI is getting replaced instead of legacy IDs after cross-walking process. Show less

• 

  UnitedHealth Group

  Sept 2008 - Apr 2009

  Sr. Business Analyst

  AmeriChoice, a UnitedHealth Group company, is devoted entirely to government health care services. AmeriChoice (AMC) had contracted to perform Government Operated - Power Account Record-keeping for State of Indiana’s “Healthy Indiana Plan (HIP)”. The concept of HIP program is to help members control their Health with tools and programs for disease management, preventive Health and wellness. HIP is new state sponsored Health Plan inspired by Health Savings Account (HSA) for uninsured low income individual from State of Indiana. Indiana was the first state in nation to implement a consumer-directed health care program for Medicaid beneficiaries. Using the State guidelines I was responsible to capture all rules that Indiana Office of Medicaid Policy and Planning (OMPP) have included for HIP while creating business requirement for the Power Account Record-keeping process. I have customized AMC’s Medicaid system based on State regulations, HIPAA compliance and product business rules. Worked on system process requirements for Member Enrollment / Reinstatement process (834), State Capitation / Power Account Contribution (820), Re-determination / Rollover Process, Termination / Refund Process and Power Account Portal to accept new X12 834 transactions for Enrollment (W) / Dis-enrollment (X), Monthly Audit File Inbound (Y), Outbound (Z) & new 820 (State Capitation & Power Account Contribution). Prioritized and confirmed all the manual & semi-manual processes (Member Enrollment to Account receivable to Lock Box remittance for Power Account) and documented for full automation. Created Test Plans that contains test scripts, test cases, test data (834 files as well as 820 files) and expected results for the Functional, Performance, User Acceptance Testing and End to End Testing. Analyzed business GAP on 4010 to 5010 conversion for Member Benefit & Enrollment - EDI HIPAA Transactions (834) and Documented AS IS and TO BE segments / Loops Show less

• 

  Presbyterian Healthcare Services

  Jul 2010 - Nov 2010

  Sr.Business Analyst

  Presbyterian has been committed to serve for a single purpose - improving the health of individuals, families and communities throughout New Mexico. The Federal mandated Project “HIPAA 5010 / ICD10 Upgrade” is the enhancement and upgrading the existing system for 5010 compliancy. This upgrade replaced the existing 4010/4010A1 version of HIPAA transactions , which go back nearly a decade—an eternity in the IT world—and address many of the shortcomings in the current version, including the fact that 4010 does not support ICD-10. In order to improve the flaws that were found in X12 - 4010 transactions since its implementation, US Government introduced X12 5010 version with additional fields and removed / changed the loop and segment to improve the data definition within the transaction. My responsibility was to capture the requirements and GAPS for 5010 Compliancy by using 5010 Implementation guidelines & to Analyze business GAP on 4010 to 5010 conversion for Member Benefit & Enrollment - EDI HIPAA Transactions. Show less

• 

  Kaiser Permanente IT

  Nov 2010 - Dec 2011

  Sr Solution Consultant

  Kaiser Permanente set yet another example by initiating The California Claims and Encounters Strategy (CCES) project for near to real time data transfer solution. The implementation of new claims platform for California Region. Replaced end-of-cycle legacy claims systems and brought in contemporary technology to the claims and encounter processing, products, pricing and customer service contributing to the competitiveness of Kaiser Permanente in California markets resulting in reduction of administrative burdens. My role as a Sr. Business Systems Analyst in this project was to create all the requirements with Business & technical for Enterprise Service Bus (ESB) translation and transformation of inbound or outbound data (Canonical Format) to or from Xcelys. The GAP analysis were done based on the Colorado vs. California State based requirement for Member and Group. Created User Stories in RallyDev for Project Tracking. Work on system process requirements to pick the Member & Group publish from Message Queue (MQ), translate and transform the canonical format to DXML format and load it into Xcelys through Xcelys service MQ. The processes include Group Publish & Member Publish which were triggered from add or changes in Membership System of Record (Foundation System), Translating & transforming data to load into Xcelys Claims platform. Show less

• 

  CareFirst BlueCross BlueShield

  Feb 2012 - Feb 2013

  Sr. Business Analyst

  CareFirst, Inc. is the not-for-profit, non-stock, parent company of CareFirst of Maryland, Inc., and Group Hospitalization and Medical Services, Inc., affiliates that do business as CareFirst BlueCross BlueShield. CareFirst, Inc. is governed by a Board of Directors and special statutes regulating its business in Maryland, the District of Columbia and Northern Virginia. CareFirst on its endless effort is building enterprise based systems that will store various aspects of data in once central store. I have been working on similar effort to build Enterprise Benefit Solutions (EBS) to store medical / version / dental and pharmacy benefit data across ASUs in a common view. Similarly working on another effort to build Communication Hub that will be the central solution for all types of communication flows from Carefirst to various internal application as well as external communication media. Continuous improvement to Member Portal through various enhancement projects Show less

• 

  Wellmark Blue Cross and Blue Shield

  Feb 2013 - Nov 2014

  Sr. BSA / SIT coordinator

  Wellmark was engaged in Quantum project in defining new products that complies to the new healthcare reform (Affordable Care Act -ACA). In order to achieve better success, its partnering with Connecture & Trizetto to implement InsureAdvantage Application and Enrollment system and FACETS to handle most of the requirement for Healthcare Reform compliancy. I started the Quantum project as Business Systems Analyst and completed the requirement documentation for Claims Integration. As Testing Coordinator and worked on Connecture enrollment system – for Small Group and IFP Member application & enrollments. My experience in Connecture application lead me to my new role as Defect Manager for production support team. With the little exposer to Quality Assurance (Testing) offshore, I wanted to explore more on this concept of Onsite / Offshore coordination hence changed my role and moved to Offshore as Offshore lead for Connecture Project. Show less

• 

  Humana

  Dec 2014 - Jan 2016

  Sr. Quality Engineering and Assurance Lead

  Humana was engaged in Responsive Web Design projects in multiple areas of health care industries. This project was focused to meet the fast growing technology needs to make their applications available in Small Device group like Smart Phones, Medium Device Group like Tablets and Large Device Group like Laptop / Desktop. Main focus is to enhance the existing Clinical Guidance eXchange CGX 1.0 (Silver lite version) to CGX2.0 (Responsive Web Design - RWD Version) that is user friendly and ease with lesser clicks for Utilization Management and Case Management processes and bring in similar process for Long Term Service Solution where LTSS is being transitioning from a different system. I was working as QE&A Test Lead Show less

• 

  Horizon Blue Cross Blue Shield of New Jersey

  Feb 2016 - Jan 2017

  Quality Assurance

  Horizon BCBS is implementing Cognizant’s TranZform product. This project was focused to meet the fast growing technology (Responsive Web Design) to make their applications available in Small Device group like Smart Phones, Medium Device Group like Tablets and Large Device Group like Laptop / Desktop. The Product will be served as User friendly Member Portal with ease of Use and lesser clicks for multiple member facing domains such as Authorization & Referral, Benefits and Coverages, Provider Search and PCP Change, Member Profiles & Preferences, Claims, Billing & Payment, Notifications. I am involved as Quality Engineer on this project to Prepare Test Design, Test Scenarios and Test Cases for various Testing Aspects. Test Design includes Domains specific test cases for Functional Testing, Batch Test Cases for Batch load specific testing & API Test cases for End to End tesing where Data transfer from Horizon’s Source System into TIL Layer and from there to TranZform UI Screen via API Service Call. Show less

• 

  EmblemHealth

  Feb 2017 - Mar 2020

  EmblemHealth is implementing Cognizant’s TranZform portal project as part of a larger CTS BpaaS deal and is part of an overall business transformation. This project will replace EmblemHealth‘s legacy external facing portals with the TranZform portals. These includes Engage Consumer (Shop&Enroll, Broker, and Employer), Engage Member, and Engage Provider. This project will replace the antiquated legacy portal technology with new technology and features/functions aligned with EmblemHealth and marketplace business needs. TranZform is focused to meet the fast growing technology (Responsive Web Design) to make their applications available in Small Device group like Smart Phones, Medium Device Group like Tablets and Large Device Group like Laptop / Desktop. The Product will be served as User friendly Portal with ease of Use. I am involved as Configuration Analyst on this project to analyze and write business requirements based on EmblemHealth’s needs Show less

  • Functional Porduct Consultant

    Jul 2019 - Mar 2020

  • Functional Product Consultant

    Feb 2017 - Mar 2020
• 

  Cognizant

  May 2019 - now

  Medicare Product Consultant

  TMS Element Product Implementation / Health Check – Cognizant Technology Solutions (Onsite) (Product Consultant - Implementation) May ‘19 – PresentProjects: Multi Client Medicare Solution Implementation projects for Medicare Advantage Plans.Elements Product Suites includes: Enrollment Administration Manager (EAM) & Workflow (EAMWF); Financial Reconciliation Management (FRM); Risk Score Manager (RSM); Risk Adjustment Manager (RAM); Prescription Drug Data Event manager (PDEM); Rx Reconciliation Manager (RxM); Claims Data manager (CDM)Clients: Centene Managed Care Corporation - 06/2024 - Present (EAM Upgrade, EAM WF Implementation) Elevance Health 03/2024 - 06/2024 (POC - Bid) - (EAM, EAM WF) Mass General Brigham – 2022, Present (Implementation/Product SME) (EAM, EAM WF, FRM) Cigna (2022 – 2024) (Implementation/Product SME) (EAM, EAM WF, FRM) Premera Blue Cross – 2023 (Documentation) EAM, EAM WF, FRM, RSM, PDEM) Prominence Health – 2023 (Implementation) EAM, EAM WF Blue Cross of Idaho – 2022 (Implementation) (RAM, RSM, CDM) Blue Cross Blue Shield of Kansas City – 2021 – 2022 (Implementation) (EAM, EAFWF, FRM, CDM) Blue Shield of California – 2021(Health check) (EAM, EAMWF) Care Source – 2021 (Health check) (EAM, EAMWF) Geisinger Health Plan – 2021 (Health Check) (FRM) Health Care Service Corporation – 2021 (Documentation) (EAM, EAM WF, FRM) Community Health Choice – 2020 – 2021 (Implementation) (EAM, EAMWF, FRM, CDM) CareFirst – 2020 (Documentation) (CDM) Blue Cross Blue Shield of Utah – 2020 (Documentation) (CDM) Community First Health Plan – 2020 (Implementation) (EAM, EAMWF) Emblem Health – 2020 (Support) (RSM) Vantage Health Plan – 2020 (Implementation) (EAM, EAF WF, FRM) Express Script – 2019 (Support) (EAM) Show less