Ashish Mahajan

Hi, my name is Ashish and I’m a Business Analyst with over 5 years of experience specializing in business requirement gathering, process modelling and Data analysis. I’ve worked extensively with payers and providers, focusing on claims adjudication, prior authorization automation, and EDI integrations, especially with 837 files and HIPAA-compliance systems.

In my current role at United Health Group, I’m part of the Claims Adjudication IT team, working on a PEGA-based case management system that processes claims submitted via multiple channels—including EDI 837 files, provider portals, and paper forms.

I was responsible for automation of EDI 837 Batch Processing and automation of Paper claim intake for virginia market. Earlier, these Paper Claim forms were sent manually, and the intake process was time-consuming. We help build a system where paper forms could be scanned, read, and automatically processed into PEGA Application.

In all above role, I was responsible for gathering and documenting business and functional requirements by conducting meetings with stakeholders. I translated Stakeholders needs into clear and actionable requirements. This included defining detailed business rules, file structures, naming conventions for EDI files, and the validation logic for checking mandatory fields such as member ID, ICD, and CPT codes.

I was responsible for creating all the core documentation for the project, including the Business Requirements Document (BRD), Functional Requirements Document (FRD), and well-defined user stories in JIRA to support Agile development. 

Throughout the project, I worked very closely with various cross collaboration team such as  QA, SFTP and PEGA developer teams to ensure the data flow was implemented correctly—from secure file intake to case creation in PEGA. I also defined the rules for generating ACK files that included clear rejection reasons, helping providers easily understand and correct issues like missing diagnosis or procedure codes.

As part of the Agile team, I participated in all key ceremonies including daily stand-ups, sprint planning, backlog grooming, reviews, and retrospectives. I used JIRA to manage user stories, track development progress, and log defects. All project documentation, meeting notes, and requirement versions were maintained in Confluence for easy collaboration and audit tracking.

For testing, I coordinated User Acceptance Testing (UAT) by preparing test cases, validating end-to-end scenarios, and working closely with QA and provider teams to ensure everything functioned as expected. I also used SQL to validate data during testing phases—for example, to check member eligibility from the FACETS database or confirm that claim details matched what was received in the EDI file I used SQL queires.

Overall, I acted as a bridge between business and technical teams, ensuring that the solution met both operational goals and compliance standards. Looking ahead, I’m eager to apply my skills in a new environment where I can help solve complex business challenges and continue learning

Business Analyst| UnitedHealth Group, Chicago                                                                                                                                     Jun 2023– Current

   Project: EDI Claims Adjudication System:

This project involved the development and support of a claims adjudication system that accepted claims through multiple channels such as provider portal, paper submissions, EDI 837 files, and fax. The system validated both member and provider eligibility and processed claims accordingly (approved, denied, or pended).

Responsibilities:

• Led the requirements gathering and analysis for EDI Claims system, conducting over 80 stakeholder meetings and workshops to document comprehensive business rules, use cases, and functional specification.
• Prepared and maintained clear documentation, including BRDs, FRDs, user stories, and test plans to support development, QA, and deployment teams throughout the SDLC
• Acted as a key liaison between business and IT teams, translating complex business needs into actionable data and system requirements, ensuring seamless EDI integration with trading partners.
• Analyzed EDI 837 claim files to identify issues, support troubleshooting, optimize claims adjudication workflows, and drive informed decision-making.
• Utilized data analysis tools such as SQL and Excel to extract and analyze complex healthcare data sets, uncovering trends and insights.
• Facilitated user acceptance testing (UAT) and provided comprehensive training for healthcare professionals, ensuring smooth transition and successful adoption of the system.
• Managed end-to-end implementation of direct connections and payer setups, maintaining compliance with industry mandates and ensuring timely file transmissions via SFTP and partner portals.
• Proposed and implemented system enhancements based on stakeholder feedback and root cause analysis, resulting in improved usability, increased user satisfaction, and reduced operational costs.
• Monitored production reports and trading partner communications, proactively addressing inbound/outbound file issues and coordinating swift resolution with internal and external stakeholders.
• Collaborated with cross-functional teams to streamline claims adjudication, improve automation, and enhance performance, security, and compliance in alignment with HIPAA and healthcare data standards.
• Managed production validation tasks during Go-Live, ensuring system readiness, data accuracy, and minimal disruption to claims and patient record operations.
• Conducted detailed gap analysis between current EDI Claims systems and proposed solutions, identifying risks and developing mitigation strategies that reduced implementation risks by over 20%.
• Coordinated with cross-functional teams during Agile ceremonies like sprint planning and backlog grooming, ensuring alignment on priorities and deliverables.

BusinessAnalyst| Wipro, India                                                                                                                                        Sep 2019 – Aug 2022

Project: Automation of Prior Authorization Submission – PEGA Case Management Application

Developed and supported a PEGA-based case management solution to streamline the intake and processing of prior authorization requests submitted via provider portals, fax, paper, and phone. The application enabled automated decision-making (approval, denial, or pending) for Utilization Management (UM) across medical, vision, and dental services.

Responsibilities:

• Led end-to-end requirements gathering through stakeholder interviews, workshops, and surveys, translating business needs into comprehensive BRDs, FRDs, user stories, and process flow documentation. 
• Contributed to an Agile project focused on streamlining the provider enrollment process within the system, participating in user story refinement, sprint planning, and backlog grooming using tools like Jira and Confluence.
• Leveraged data visualization tools such as Power BI to create interactive dashboards and reports for healthcare stakeholders, providing insights into key performance indicators and enabling data-driven decision-making in clinical operations
• Collaborated with compliance teams to ensure all workflows met healthcare regulatory standards, especially in claims adjudication and prior authorization processing. 
•  Directed a team of Business Analysts, managing task allocation, milestone tracking, and serving as the primary liaison between stakeholders and the development team. 
• Facilitated sprint planning, backlog grooming, and user acceptance testing (UAT) within Agile ceremonies, ensuring alignment with business objectives and timelines. 
•  Reviewed system requirements, test cases, and user stories in JIRA, actively participating in defect triage and resolution to maintain quality standards. 
• Conducted walkthroughs with QA, Dev, and UAT teams to validate requirements and ensure accurate implementation. 
• Delivered end-user training, supported change management initiatives, and oversaw smooth go-live transitions for newly implemented processes

Business Analyst|HCL Tech, India                                                                                                                                               Jul 2018 – Aug 2019

• Managed Salesforce CRM and Google Analytics, enhancing data accuracy by 25%, demonstrating strong analytical skills and expertise in data-driven decision-making for IT projects.
• Gathered and defined the technical and business requirements for implementing sentiment analysis tools to track and evaluate customer feedback on social media platforms, establishing clear objectives and performance metrics.
• Applied sentiment analysis tools to monitor customer feedback across social media, effectively utilizing emerging technologies for social listening and sentiment analysis in IT projects.
• Utilized collaboration platforms like Confluence and Trello to streamline project management, improving cross-functional team communication and increasing project efficiency by 30%.
• Assessed risks related to third-party vendors or service providers for IT platforms, data analytics tools, and cloud services, identifying potential risks such as service disruptions, contract issues, or changes in service terms.
• Facilitated stakeholder and end-user participation in User Acceptance Testing (UAT), ensuring that testing processes met business and technical requirements and aligned with stakeholder expectations.
• Systematically documented requirements, decisions, and outcomes from Joint Application Development (JAD) sessions, ensuring 95% clarity and alignment among stakeholders for IT project success.
• Tracked key performance indicators such as website traffic, bounce rates, and engagement metrics to evaluate the impact of sentiment analysis and CRM systems on customer interaction and business outcomes.
• Developed and maintained budgeting and planning models in Excel, managing resources, tracking IT project expenditures, and forecasting revenues based on performance data and historical trends.

Masters in Information System