Waseem Mohammed

Contact: 203-685-5727
Email: waseem_u@yahoo.com

Professional Summary:
Extensive history in the healthcare payer field within areas of medical management, prior authorization, third
party recovery operations, eligibility and enrollment, managed care, contract monitoring, provider management
and operations. Expertise in Software Development Life Cycle (SDLC), Business Process Improvement (BPI),
Business Requirement Process, (BRP), BRD Business Requirement Documentation. Good understanding
Medicare and Medicaid space and MMIS systems.

Summary:
 Over 15+ years of experience in healthcare payer space working as Business Analyst and Project Manager.
 Experience in implementation/maintenance of payer payment solutions for Govt Programs.
 Working experience with deep understanding of business processes and IT landscape within Medicare and
Medicaid Information Systems and CMS MARx Enterprise system.
 Experience in Business System Analysis, Requirement Management, Business Process Modeling, Product
Management and Project Management.
 Strong analytical skills with proven record of synthesizing large amounts of structured and unstructured data
into easy to understand insights tailored for all relevant audiences’ to solve business problems.
 A passion for identifying root cause of problems with an ability to propose and recommend innovative
solutions to diverse stakeholders.
 Experience in identifying gaps in processes and closing them as part of continuous process improvement.
 Experience in creating AS IS and TO BE process flows as part of GAP analysis
 Experience working with end users to create business and functional requirements and applying structure to
loosely defined complex problems.
 Experience working in global settings with senior level stakeholders, client leadership and be the liaison
between the business units, product and support teams.
 Experience in project planning activities, business analysis, data analysis, impact analysis, business
requirements documentation, process modelling and UAT planning/execution.
 Working experience on Enrollment, Eligibility and Claims systems like NASCO, EAM, FACETS, QNXT etc.
 Technical writing skills include drafting contracts, SOP’s, user manuals and system configuration guides
 Experience in industry improvement standards like Six Sigma, Capability Maturity Model (CMM) and SOX
 Skilled at building relationships, active listening, and reading the underlying dynamics of different groups

Education:
Masters in Technology Management. Connecticut, US.
Bachelors in Electronics and Communications, INDIA.
Certifications for Business Process Modelling and Project Management from Blue Cross Blue Shield

Skills:
Documentation Tools: MS Word, Excel, Power Point, MS Project, SharePoint, ClearQuest, JIRA and Confluence
Process Models: UML, MS Visio, Blue Works Live and Snagit
Databases: Oracle, Microsoft Access, SQL Server, MS Team Foundation Server, MS Dynamics 365
Méthodologies: SDLC, Waterfall, Scrum-Agile
Professional Experience:
Blue Cross Blue Shield, MN (Remote) April 2023 – Current
Senior Business Systems Analyst
 Worked within MOM-T (Medicaid Operating Model - Transformation) program
 Worked on Provider Network & Stakeholder Interfaces workstreams to align with enterprise strategy
 Gathered and analyzed information to formulate scope and objectives of MOM-T technology solutions
 Interacted with the client and the Technical teams for business requirements gathering and translation
 Worked on Facets platform to bring in Claims Administration Program Solution (CAPS) in-house to BCBSMN
 Worked on Provider Credentialing, Provider demographics, Provider portal (Availity), Networks and
Directories to support Dental provider area
 Facilitated requirements elicitation sessions with different business areas and vendors (Prime therapeutics
and Delta) to document requirements
 Worked on vendor systems integration to build eligibility and claims feeds for file transmissions
 Performed data mapping for file layoutout (TPL file from Department of Human Services, Flat files, 834, 837)
 Worked on Member ID card viewer implementation in Provider portal Availity via real-time API’s with a good
understanding of HTTPS POST request and JSON response
 Identified and documented the dependencies between the business processes
 Implemented solutions to create membership files in Pega to allow business teams to generate COB data
 Created and groomed user stories for development tasks and used Jira as a tool to maintain backlogs
 Participated in testing efforts and post production triage support.

Independence Blue Cross (IBC), PA (Remote) Mar 2022 – Mar 2023

Senior Business Systems Analyst
 Worked within Commercial Digital Health implementation space for different lines of businesses (Fully
Insured, Self Funded, AmeriHealth PA, AmeriHealth NJ, TPA like enGen etc)
 Worked on enhancements to new/existing consumer products and programs as part of NextGen initiative.
 Worked within Independence Clincal management area for Behavioral Health Auth data load to TPA enGen.
 Created E2E operational workflows in conjunction with TPA as part of claims administration and recon.
 Performed business system analysis to define and document business requirements based on future state.
 Prepared data mapping document for developers to generate reports and ran SQL queries to extract data.
 Worked on Microsoft Dynamics 365 as part of customer relationship management (CRM).
 Mapped client requirements with Microsoft Dynamics CRM application functionality.
 Worked on projects within Agile methodology or frame work to create user stories and acceptance criteria.
 Implemented processes for provider claim inquiries, claim status & customer service on MS Dynamics CRM
 Collborated with business stakeholders to help in decision making process for based on solution design.
 Worked closely with stakeholders and SME’s to document scope of project tasks, activities and deliverables
 Facilitated requirements elicitation sessions with different business areas to document requirements
 Created deliverable like High Level Vision and Scope (HLVS), BRD, User Stories, Backlogs, RMP, RTM etc.
 Identified gaps in business processes and made recommendations in process improvements
 Involved with UAT planning and execution of test scripts.

Caresource, OH (Remote) July 2020 – February 2022

Senior Business Systems Analyst
Responsibilities:
 Worked on Vendor Oversight program that enabled vendor delegation of benefit set up for new markets for
MA DSNP lines of business and Commercial Digital Health projects for Self Funded and Fully Insured clients.
 Created vendor documentation and served as subject matter expert for assigned Supplemental Benefit and
represent department in business development and integration efforts.
 Worked on enrollment transactions and claims file transfers with delegated vendors
 Worked on the automation and validation of TRR’s and member letters as part of enrollment process
 Assisted with implementation of Supplemental Benefit strategies and stakeholder communications.
 Established and strengthened relationships with Executive Sponsors, Business Owners and vendors.
 Facilitated operational and strategic meetings, including requirements gathereing sessions for Supplemental
Benefit contract management, identifying/resolving/escalating issues and monitor vendor Corrective Action
Plans (CAP’s) to close out action items.
 Worked on CMS Interoperability Mandate implementation to make a patient data (claims and encounter)
available via the Patient Access API using FHIR (Fast Healthcare Interoperability Resources) standard.
 Created user stories, acceptance criteria and maintained sprint backlogs using Jira as a tool.

Express Scripts, NJ July 2018 – June 2020

Senior Business Analyst/Govt. Solutions Product Manager
Responsibilities:
 Worked on new client implementation of Trizetto’s Enrollment products (EAM and Facets) for Medicare
Advantage and Medicare Advantage Prescription Drug plans for Express Scripts PBM.
 Owned product roadmap by managing stakeholder priorities in collaboration with multiple delivery teams.
 Partnered with client partners to understand current and future consumer experiences, challenges, and
subsequently develop scalable solutions for the products.
 Managed product enhancements and key features for Medicare Enrollment process like BEQ
configuration/processing, automation of EAF fallouts, EGWP (Employer Group Waiver Program) processing.
 Evaluated and identified required CMS compliant system enhancements and assisted in new client
implementations and product features.
 Analyzed and groomed product requirements for features and workflows as part of client implementation.
 Collaborated with implementation, configuration and product teams in implementing enrollment product
for health plans with Medicare Advantage EGWP business.
 Created requirements documents, use cases and protypes to demo and articulate product functionality and
receive buy-ins during customer focus group calls.
 Experience in writing product user stories, acceptance criteria and grooming backlogs for Medicare products
 Partnered and ensured clear communication and coordination across design team, engineers, project
managers, and IT teams to own and deliver end-to-end customer experiences.
 Worked with the agile scrum team to craft customer-centric user stories or business requirements.

Anthem, VA (Remote) July 2017 – June 2018

Project Requirements Manager/ Senior Business Analyst
Responsibilities:
 Experience in the provider space (provider and payers; provider finder/demographic etc.)
 Responsible for working with Business and IT stakeholders to understand the provider domain and provide
analysis to capture and manage quality requirements that align with the system solution.
 Experience working in Agile environment as Requirements Quality Manager - Creating Epics, User Stories
 Primary duties included developing epics and delivering quality requirements across cross functional teams
in the form of user stories using agile principles and mindset to accomplish deliverables.
 Scheduled user story elicitation sessions with impacted systems (EPDSV2, ACES, WGS, CPF, CPMF).
 Managed and took ownership of requirements for Provider demographics area which were consumed by
downstream systems (WGS ) for claims processing and adjudication via “WGSP-WGS Provider”.
 Thorough subject matter expertise and an understanding of business processes by working closely with
Business Owners, Product Managers and/or Product Owners to ensure business needs are captured,
prioritized and understood to manage stakeholder expectations.
 Provided support during the integration, acceptance testing phases and implementation.
 Used Jira as requirements management tool.

Horizon Blue Cross Blue Shield, Newark NJ Aug 2012 – July 2017
Projects Implementation Manager/Senior Business Systems Analyst
Responsibilities:
 Experience as a key lead role in major enterprise wide company initiatives within payer space.
 Demonstrated leadership and acted as a representative for IT Enterprise Initiatives
 Responsible for leading teams and other resources to ensure alignment of technical solutions with business
requirements and processes.
 Strong understanding of ESB architecture (Enterprise Service Bus)
 Analyzed business needs and requirements of the stakeholders and translating them into functional and
technical specifications which supported ESB (Enterprise Service Bus) perspective
 Worked on multiple enterprise wide IT implementations for state sponsored (State of NJ) Medicaid
programs like MLTSS, DSNP and NJ DCF (Dept of Children and Families).
 Implemented solution to create UI in Pega to allow business teams to generate letters and and route to print
vendor for member/provider mailing lists.
 Managed implementations of new medical management system for Commercial and Medicaid line of
businesses; Physical and mental health care for Adolescent services; Out of Network Reimbursement
Strategy project for Pricing; Provider self-service portal to submit authorizations; Automation of enrollment
paper applications for MA, DSNP and PDP members – Print on Demand; Enhancements to NJ Choice data
exchange process between state of NJ and HNJH for MLTSS population; Automation of Medical Appeals mail
intake process; Integration of Medicare into Govt. Programs as part of Government Programs Restructuring;
Self Service Claims Adjustment request for provider community and other various delegation projects like
Magellan FTP claim file and Magellan IVR etc.
 Created artifacts like IRF’s (Initial Request Form), PA estimates (Planning Approximation), BRD’s, RMP’s
(Requirements Management Plan), OSP (Ops Support Plan) etc.
 Created workflows for clinical work streams that were part of new MMS CareRadius system implementation
- Prior Auth, CM, DM, CCM, and Appeals process, Quality, Complaints and Grievances etc.
 Provided SME direction to the portfolio and ensured all documented requirements supported delivery of
business value and met stakeholder’s needs.
 Presented project status update reports to the leadership teams and deployed tools and methodologies (ex.
SIPOC) to identify process and operational efficiencies to minimize operational costs
 Utilized IBM’s “Blue Works Live” tool to produce high quality process modeling artifacts
 Lead UAT planning, execution and documented UAT test cases and supported users during UAT.
 Worked collaboratively with SIT and Dev teams and took ownership of issues and drove to closure.
 Ensured issues identified were tracked, reported and resolved in a timely manner.
 Participated in project meetings to review progress, address issues and mitigate risks.
 Prepared detailed project plans to track and review progress and project performance
 Developed solutions to solve business problems across business areas and presented to business teams
 Identified and presented new project opportunities to leadership.

Maximus Inc. (Remote) Jan 2012 – July 2012

Lead Business Consultant
Responsibilities:
 Worked within Program Modernization Solutions group and successfully implemented PDMS (Provider Data
Management System) for State of Tennessee’s Medicaid program to accept enrollment and recertification
requests for different provider types - Department of Children’s Services (DCS), Department of Intellectually
and Developmental Disability Providers and different physician groups
 Elicited and documented business requirements, business rules for handling groups and facilities in PDMS
 Documented current/future state workflows for New Provider Registration and Provider Recertification
 Documented data migration process and performed data mapping of provider data within TennCare MMIS
to PDMS database
 Worked with Enterprise Architects to explore design solution options and review with the state.
 Facilitated weekly/bi-weekly status meetings for assigned products and reviewed client agendas/statuses
 Documented detailed specs for issues identified as part of post-production support.
 Coordinated builds from DEV to Integration Testing, Integration to UAT and UAT to PROD.
 Collaborated with client to obtain sign-offs on UAT testing and PROD builds

Otsuka Pharmaceutical, Princeton NJ July 2011 – Dec 2011

Systems Analyst/Project Manager
Responsibilities:
 Worked on CDR (Commercial Data Repository) project for commercial line of business
 Responsible for managing cross-functional teams to deliver project on time and within budget
 Responsible to oversee project requirements, forecasting analysis and manage working relationships with
project stakeholders, internal and external clients and vendors
 Responsible for overall planning, including tracking progress and issues in order to manage expectations
 Responsible for business/data analysis, data reporting, mapping of data sources, table updates etc.
 Responsible for producing reports from various sources to provide business with actionable information
 Acted as a liaison between IT, Vendors and business customers to present recommendations which included
requirement gathering project prioritization across IT and respective Pharma and Consumer business units.

Express Scripts - Franklin Lakes NJ Jan 2011- June 2011

Senior Project Business Analyst/Project Manager
Responsibilities:
 Worked on migration project within cross-functional project team to provide business analytical support
 Documented clients functional and transactional requirements
 Took ownership of issues and executed work plan for issue resolution
 Created executive project tracking summaries for leadership and escalated issues when appropriate
 Worked with other teams (e.g. Dev/QA and vendor teams) to schedule fixes
 Ensured Issue logs are always up to date and lead issue readouts in lightning rounds
 Ensure successful "hand-off" to other teams when required and communicated with all levels of leadership
 Played client facing, consultative role and offered system solutions to enhance client implementations

Alere Inc (now Optum) - Upper Saddle River, NJ July 2009 – Dec 2010
Senior Business Analyst/Product Manager
Responsibilities:
 Responsible for the planning, execution and ongoing administration of multiple products within the PDBA
(Product Design & Business Analytics) division.
 Prioritized product requirements and defined a roadmap for FDA approved oncology drugs.
 Acted as SME on the product to support stakeholder engagement, sales and marketing, Client management,
 Collaborated with Operations team to ensure business goals are achieved throughout products lifecycle.
 Established & maintained comprehensive understanding of regulatory requirements for approved products
 Worked on multiple Bio-Pharma products for Oncology program and in-house web based medical
management and pharmaceutical applications (“IHMS” & TRAX)
 Experience managing external client partners (Genentech/Novartis) with client-facing consultative skills
 Developed Use Cases and clinical workflows for FDA approved oncology/cancer drugs
 Collaborated with medical writers to develop scripts for all approved FDA drugs as part of content mgmt.
 Collaborated with Client Managers and end users to document product specific requirements
 Acted as liaison and an advisor to operations and clinical teams by providing technical/functional support
 Collaborated with leadership to define product strategy to develop and execute related product roadmaps
 Support activities included mapping of user requirements to existing applications and develop wireframes
 Prepared management reports on business initiatives, issues and facilitated requirements walkthrough
 Worked on reporting to analyze and consolidate web reports through GAP analysis for Oncology products
 Documented business processes and identified opportunities for improvement
 Performed UAT by emulating different roles like TEN (Triage Enrollment Nurse), Care Managers and MD’s
 Created UAT test scripts for Oncology program and validated that the application is performing as designed
 Worked closely with Dev/QA teams throughout project lifecycle and helped interpret business requirements
 Identified defects reported by user community and gave closure

Cigna Healthcare - Bloomfield, CT Jan 2008 – June 2009

Senior Business/Systems Analyst
Responsibilities:
 Worked on a web based application called “CIGNA OneView” within Enterprise Application Services area
 Worked on SOA (Service Oriented Architecture) business models/governance, and Enterprise Service BUS
 Working knowledge of SOAP, Schemas, WSDL’s, XML’s, SQL and stored procedures
 Created artifacts like FSD, Data Sheets, Invocation Outcome and the Business Conditions document
 Created flow diagrams to represent functionality of service operations and conducted internal reviews
 Worked on multiple operations across Member, Claims and Provider domains (ex: request replacement of
pharmacy id cards, search member, plan sponsor account notes, search claim by identifiers etc)
 Participated in design reviews with the designers to validate that the design is as per functionality defined in
the Functional Specification
 Coordinated with the business/technical teams to set up SOA Governance and SLA’s for service operations
 Facilitated consumer reviews for Service Operations and responsible for end to end Service roll outs

The Hartford Insurance Group – Hartford, CT Jul 2005 - Nov 2007

Lead Business Systems Analyst / Project Coordinator
Responsibilities:
 Worked within DMO (Data Management Optimization) group for CLDW (Commercial Lines Data warehouse)
 Performed business analysis for P&C actuarial and underwriting systems to document business
 Analyzed data sources and their target data marts as part of commercial lines data source consolidation
 Performed data grouping and created data flow diagrams to represent the data mapping.
 Performed data mapping with respect to the IIW (Insurance Information Warehouse) subject areas.
 Performed data analysis and data mapping activities for ETL processes.
 Worked in collaboration with SAS experts during SAS installations and configuration.
 Responsible for all project management activities as a part of project planning phase.
 Responsible for documenting requirements to produce artifacts such as BRD, SRD and FSD.
 Performed gap analysis and participated in brainstorming sessions with stakeholders and ETL teams.
 Facilitated sessions with the business/stakeholders for decision making, issue resolution and status update.
 Created test plan and test cases and executed SQL queries using TOAD to validate data.
Cigna HealthCare - Bloomfield, CT Jan 2005 - June 2005
Business Analyst
Responsibilities:
 Worked within PPR (Project Process & Requirements) group to implement Non CIGNA PBM project to
automate information sharing for accumulators with ESI and Medco.
 Responsibilities included analyzing and documenting business requirements, use cases and facilitation of
requirements gathering sessions with business SME’s and other third party vendors.
 Documented business rules and business process models based on process impact assessments.
 Participated in all end to end review sessions and validation sessions

Fannie Mae – Washington, DC Oct 2004 - Jan 2005

Business Analysts / Technical Writer
Responsibilities:
 Worked on the “Single Family Restatement” project and managed and maintained workstream
documentation according to Sarbanes Oxley (SOX) 404 controls/standards per Fannie Mae’s SLCM (Software
Lifecycle Methodology).

Liberty Bank - Middletown, CT Jan 2004 – Sep 2004

Business Analyst / QA Analyst
Responsibilities:
 Worked on web based application “Biz Link with Cash Management” to provide online access to business
accounts for cash management, transfers and payroll direct deposit purposes.

Consumers Mortgage Corporation - Middletown, NJ May 2003 - Jan 2004

Business Analyst
Responsibilities:
 Worked on “Home Loan Wizard” and Refinance Guide designed that provided customers ability to self-
assess and determine loan programs for refinancing and other mortgage lending services.

Health Insurance Plan of New York - NY Nov 2002 – Mar 2003

Business Analyst
Responsibilities:
 Worked on an integration project with an existing web based application for online claim submissions.

Glaxo Pharmaceuticals, Cambridge – Cambridge, MA Jan 2002 - Sep 2002

Business Analyst
 Worked on EDR application used to store and retrieve research data