Vijay Abothu

Background

About Vijay Abothu

Profile Summary • Over 12+ years of progressive experience as a Business Analyst in the Healthcare industry with strong domain expertise in Healthcare Payer and Healthcare Administrator operations, Third Party Administrator (TPA) management, Blue Card program support, Benefits & Claims Administration, and large-scale Vendor Integration projects. • Proven track record in leading benefits and claims administration process improvements, claims adjudication, eligibility verification, and benefit plan configuration for major healthcare clients including Delta Dental, CVS, UnitedHealth Group, and BCBS. • Skilled in managing Healthcare Payer and TPA migration initiatives, vendor onboarding, and cross-network Blue Card claims processing, ensuring compliance with CMS, HIPAA, and state-specific regulatory requirements. • Expertise in bridging business and technical teams to deliver Vendor Integration solutions for claims processing, benefit configuration, and provider contract management, resulting in measurable efficiency gains and reduced operational costs. • Adept at facilitating JAD sessions with Healthcare Payers, TPAs, Blue Card networks, and vendor partners to define requirements, streamline integration processes, and accelerate project signoffs. • Strong background in Benefits & Claims Administration lifecycle, including setup, adjudication, utilization management, coordination of benefits (COB), and process automation to improve turnaround times. • Experienced in data migration, validation, and reconciliation testing for payer systems, ensuring 100% business rule alignment during transitions from legacy platforms to modern claims administration systems. • Experienced in Agile, Waterfall, RUP, and hybrid SDLC methodologies, consistently delivering healthcare projects aligned with regulatory standards and business objectives. • Having good experience working with clients onsite. Experienced in Medical Processing and Hospital Claims. • Good Experience on Claims Test Pro (CTP) • Good Experience in QNXT Claim Adjudication system. • Experience in Claims Editing & Rating system (iCES) • Worked in high end process of Benefit configuration (Certificate of Coverage & SCI iBAAG). Also have experience in customizing iBAAG templates used for creating Benefit documents which is used for Claim Adjudication. • Several years of experience and advance knowledge of the Systems Development Life Cycle (SDLC), Waterfall, Agile, Scrum, Spiral, Extreme Programming (XP), and Rational Unified Process (RUP).