About
Parth Jani is a seasoned and highly accomplished Healthcare IT professional with a strong portfolio in enterprise-level project management, business systems consulting, and technology-driven healthcare solutions. With a Master’s degree in IT Management and a decade-plus of real-world experience, Parth has earned a reputation for excellence in healthcare technology by consistently leading and delivering strategic, regulatory-compliant, and patient-centric projects across multiple healthcare domains.
Parth’s career trajectory showcases a deep command over the Healthcare IT landscape, marked by substantial hands-on involvement in Medicaid and Medicare programs, Revenue Cycle Management (RCM), pharmacy benefits, Electronic Data Interchange (EDI), and enterprise-level integration using standards like HL7, FHIR, and OMOP CDM. He has operated in roles including Senior Project Manager, Product Owner, Business Systems Analyst, and Scrum Master, adapting to both leadership and hands-on technical environments with equal agility.
One of Parth's major strengths lies in managing complex implementations across diverse systems and stakeholders. He has led large-scale initiatives for industry leaders such as Molina Healthcare, Florida Blue (BCBS FL), CareSource, Sentara Health Plans, and AmeriHealth. His expertise covers the full Software Development Life Cycle (SDLC), both in Agile and Waterfall environments, and includes requirements gathering, stakeholder management, sprint execution, backlog prioritization, and user acceptance testing. Parth has also played a vital role in supporting critical compliance projects like CMS Interoperability, Transparency in Coverage, the No Surprise Act, and ACA mandates, showcasing his detailed understanding of regulatory frameworks and payer-provider data ecosystems.
He is highly proficient in tools and technologies used for business process improvement, data analysis, and healthcare informatics. These include Tableau, Power BI, Informatica, Microsoft SQL Server, SSIS, Azure DevOps, JIRA, Salesforce Service Cloud, SOAP UI, Postman, and more. His skillset extends to interface engine development using Rhapsody and experience with cloud integration, data migration, and API testing. Notably, he’s worked extensively with healthcare payer platforms like QNXT, FACETS, PEGA, and HealthEdge, implementing enhancements and configurations to streamline operations and improve auto-adjudication of claims.
Parth has deep functional experience in Care Management, Utilization Management, Pharmacy Benefits Management (PBM), Digital Marketing Portals for member engagement, and Provider Data Management Systems. At Molina Healthcare and CareSource, he contributed significantly to the development and enhancement of care coordination portals, accumulators, and clinical vendor integrations. His role often involved translating regulatory and business requirements into scalable IT solutions, bridging gaps between business and technical teams, and facilitating organizational change management initiatives.
As a certified Agile practitioner and experienced Scrum facilitator, Parth has led cross-functional teams through product backlog refinement, sprint planning, daily scrums, sprint reviews, and retrospectives. His leadership was crucial in transitioning teams from traditional Waterfall to Agile and SAFe frameworks, enabling better delivery cadence, responsiveness, and team productivity. He also played a critical role in developing training material, mentoring new hires, and building scalable knowledge repositories.
Parth’s analytical mindset and communication skills are reflected in his ability to conduct SWOT analyses, lead Joint Application Development (JAD) sessions, and prepare functional and technical documentation such as Business Requirement Documents (BRDs), Functional Requirement Documents (FRDs), and Requirements Traceability Matrices (RTMs). He has worked with multiple stakeholders including state agencies, vendors, compliance units, and product teams to ensure timely delivery of high-quality, compliant solutions.
What truly sets Parth apart is his ability to balance deep technical knowledge with strategic business insights. He is adept at evaluating system limitations and crafting customized solutions that align with enterprise goals while ensuring compliance with healthcare standards such as HIPAA, HL7, ICD-10, and more. His dedication to continuous improvement, automation, and innovation makes him a valuable asset in any healthcare technology initiative.
In summary, Parth Jani is a versatile and forward-thinking IT leader with a rich blend of technical, analytical, and leadership skills. His comprehensive experience across health plans, regulatory programs, and enterprise-level implementations positions him as a thought leader and problem solver in the ever-evolving field of Healthcare Information Technology.
Skills & Expertise
Visual Studio
Tableau
Power BI
SSIS
MS Access
SQL
Agile
HTML
XML
Microsoft Office
Windows
Project Management
MS Project
MS Visio
Microsoft Visio
Azure DevOps
Waterfall
SharePoint
JIRA
DICOM
Azure
TFS
MS SQL Server
Hybrid
ALM
Agile Methodology
Agile Methodology
SOAP UI
Rally & TFS
Project Management Server
AppTio
SNOW
IBM Blue Works
Lucid Charts
POSTMAN
Visual Studio TF
MAC & Linux
WEB Services
Figma
EPIC
FACETS
QNXT
PEGA
FHIR
HL7 Data Exchange
SQL Server Integration (SSIS)
Informatica Power
HL7 V2.x
HL7 V3.0
CCD
IHE
CDA
ASTM
Mirth connects
Ensemble
Rhapsody
EDI
EDIFECS
SOAP validation
SQL & MS SQL Server
Informatica ETL Tools
Tableau Reporting
Power BI Analytics
HL7 Integration
FHIR API Usage
Rhapsody Interface Engine
OMOP CDM
Salesforce Service Cloud
EDI X12 Transactions
JIRA Project Tracking
Web Services & APIs
Postman & SOAP UI
SSIS & Data Warehousing
EPIC Systems
TFS & ALM
Data Mapping & Analysis
JSON/XML Parsing
API Gateway Management
Mirth Connect
Revenue Cycle Management
Claims Adjudication
Medicaid & Medicare
C (Programming Language)
Technical Solution Design
Software Development
Unix Administration
Application Programming Interfaces (API)
Technical Architecture
Business Management
New Business Development
Research Interests
Artificial Intelligence
Project Management
Robotic Process Automation
Managed Care
Healthcare IT
Revenue Cycle Management
Claims Adjudication
Medicaid & Medicare Programs
Pharmacy Benefits Management
Business Process Improvement
EDI Transactions
HL7 & FHIR Standards
Care Coordination
OMOP CDM Integration
Provider Network Management
Utilization Management
Agile Delivery Models
Data Analytics & Visualization
Clinical Data Exchange
Digital Health Solutions
Risk Adjustment Analytics
HIPAA & CMS Compliance
Health Information Exchange (HIE)
Provider Network Management
Provider Data Management System
Utilization Management
Care Management
Clinical Vendor Management
UMCM Data Analytics
UM Pega
Risk Adjustment
Special Investigation Unit
Medicaid Systems and Reporting
Claims Data Reporting
Pharmacy Benefits Management and Reporting
Behavioral Health Reporting Magellan
Population Health Data Analytics
Care Coordination
Pharmacy Benefits Management
Connect With Me
Experience
IT Project Manager
Project: Molina Healthcare is an organization which adjudicates, and processes claims for health care, As a IT project manager
and product owner in the Agile environment on development of Care Management, EDI Transactions, QNXT, Pharmacy Benefit
Management PBM & Care Coordination Portal for all the Molina Health Plans across the United States.
• OH Medicaid – Procurement (State Project - Availity)
• Availity (Care Coordination Portal)
• Availity - Digital Marketing (Provider Portal)
• Utilization Management Vendor Delegation (UMVD)
• Enterprise Clinical Vendor Intégration (ECVI – Program)
• UM Pega New Feature (UM Pega)
• UM Pega (Letters)
• Pharmacy Benefit Management (PBM – Enhancement)
Responsibilities:
• Initiated and facilitated all Agile ceremonies and provided Agile coaching to teams on all aspects of the project management
framework, with a strong focus on Scrum practices.
• Proven competence in the area of application development, maintenance, and support for leading financial services client
such as Unisys, health care Payors such as Molina Healthcare Technology side and Healthedge clients like POMCO and
Riverside Domain side. Worked as a Technical analyst/Business consultant with HealthEdge Payor system organization
specifically for the clients POMCO and Riverside Benefits and claims administrative organization
• Develop and maintain a program delivery road map which encompasses planning, development, monitoring, control, and
execution
• Managed end-to-end project lifecycles using ADO, including requirement gathering, sprint planning, backlog management,
and release coordination.
• Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare
and Medicaid.
• Experienced in Claims Master and Revenue Cycle Management (RCM) suite.
• Customized Salesforce Service Cloud workflows, escalation rules, and automation processes to align with healthcare
regulatory requirements and compliance standards
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain an up-to-date list of payer
contacts.
• Written multiple use case for multiple transactions on Membership enrollment EDIFECS 834 (Benefit Enrollment and
maintenance) for enrolling members in a health plan.
• Experience in integrating diverse datasets (EHR, claims data, registries) into the OMOP CDM framework.
• Responsible for the regulatory management process for the services provided by the pharmacy and Interacted with the
Gainwell team to gather requirements for OH Re-Procurement project.
• Assisted with the development of Change management plans and assisted with organization change management (OCM)
activities as part of a large-scale system (SACWIS) implementation.
• Worked with testing team for testing the requested web services in JSON format using Apigee and validation of HL7
message via FHIR API using POSTMAN and documented RESTful API and Streaming API with the help of SWAGGER
• Collaborated with cross-functional teams, including finance, clinical operations, and IT, to gather requirements and develop
business cases for payer pull through initiatives.
• Prepared requirements for charter and understanding the process of Med d flows related to Claims and Accumulator.
• Customized Salesforce Sales Cloud workflows, validation rules, and automation processes to align with healthcare
regulatory requirements and compliance standards
• Evaluate current QNXT system configuration for Medicare Advantage and Medicaid plans and recommend configuration
improvements to increase auto adjudication of claims.
• Gathered and documented specifications for web services for updating contents, data, and features.
• Analyze current configuration team SLA service level agreement and recommend more standard SLA across team members
based on QNXT knowledge levels.
• Conducted business process analysis and workflow modeling to identify gaps, inefficiencies, and opportunities for
improvement within HIX enrollment, eligibility determination, and plan management processes.
Parth Jani
• Develop training program and material for new hires and existing configuration team members
to increase QNXT knowledge base and facilitate cross training within configuration department.
• Created specification for the front-end using wire frames.
• Moved data from source tables into the centralized database for reporting purposes using Informatica.
• Validation and/ or updating of accumulators in benefits plan configuration.
• Review of claim history to determine if limits and accumulators were calculating within the system correctly.
• Analyze and develop gap and custom solutions when QNXT system cannot meet required business needs.
• Implemented Agile/Scrum Methodology to projects through iterative approach to expedite project milestones.
• Prepared test cases and performed functional, acceptance, and regression testing.
Sr. Product Owner/Project Manager
CMS Projects (No surprise act, Transparency in Coverage & CMS Interoperability)
• Digital & Marketing – Member Portal
• Digital & Marketing – Florida Blue int. with TPV
• Digital & Marketing – Truly for Health
• Digital & Marketing – CAI (Chabot)
• Digital & Marketing – POR (Personalization, Orchestration & Reporting)
• Member Portal – Redesign (Enhancement Project)
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating user stories and prioritizing
user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
• Established a Business Analysis methodology around Agile (SDLC) methodology.
• Managed data submissions for Medicaid, Medicare, and commercial health plans, ensuring compliance with state and
federal regulations.
• Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare
and Florida Medicaid.
• Used MS-Visio for flow-charting, Use- Case process model and architectural design of the application.
• Using Shared Containers and creating reusable components for local and shared use in the ETL process.
• Effectively communicated and assisted other team members in ongoing assignments as part of an agile environment.
• Direct contact with the payer on behalf of the provider to discuss claim rejection reasons concerning claims and enrollment
• Participated in SAAS system design and integration.
• Gathered and documented Project requirements for payer pull-through projects, ensuring alignment with organizational
goals and compliance standards.
• Conducted business process analysis and workflow modeling to identify gaps, inefficiencies, and opportunities for
improvement within HIX enrollment, eligibility determination, and plan management processes.
• Worked closely with compliance teams to ensure HIX systems and processes adhere to healthcare regulations, including the
Affordable Care Act (ACA), Health Insurance Portability and Accountability Act (HIPAA), and other federal and state
mandates.
• Set up Data Profile and Scorecards using Informatica Developer Tool to monitor the quality of data, as a part of the Data
Governance initiative.
• Managed projects related to OMOP implementation and data analysis, ensuring timely delivery and alignment with business
goals.
• Update Plan configuration to ensure member and family accumulators and limits reflect sales’ contracts documents.
• Experience in Revenue Cycle Management (RCM) for claims processing.
• Analyzed trading partner specifications and created EDI mapping guidelines Created the JIRA/SQL scripts for demonstrating
the prototypes and for verifying the result sets and used SDLC (System Development Life Cycle) methodologies like the RUP
and the waterfall.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases, Test Plan & Test Scripts that
were executed during testing process and used edifecs for specs development.
• Provided data analysis and insights into healthcare service leadership using Salesforce Service Cloud data, identifying service
trends, patient satisfaction metrics, and areas for improvement
• Performing brainstorming session with engineering, data management and ETL team.
• Involved in Data Analysis & Mapping to track all data elements used in the application from the user interface through
different interfaces to the target databases in which they are stored.
Sr. Business System Analyst/Product Owner
Project: CareSource is a healthcare service company dedicated to improving the health, well-being, and peace of mind of those
they serve. They offer an integrated suite of health services that affiliate medical, dental, behavioral health, pharmacy, vision,
supplemental benefits, and other related products. My role was to elicit, analyze, communicate, and validate requirements for
changes to business processes, also to understand business problems and opportunities in the context of the requirements and
to translate those requirements into solutions that enable projects and the organization to achieve their goals.
• OH - State Medicaid (ODM Procurement Program)
• Finance Integrity Project (EDI 835RA inbound/outbound)
• CMS Projects (No surprise act, Transparency in Coverage & CMS Interoperability)
• Care Management (Care Coordination Portal)
• Real Time Claims Payment
• Accumulators and Claims Adjudication
• Enrollment
• Facets Upgrade 5.8 (R1, R2 & R3)
• Digital Marketing (Member Portal and Provider Portal)
• Provider Platform
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization,
• Assist in the development of a Business Plan for the future of Health Edge's web presence applications that are wrapped
around the organizations core enterprise-wide claims processing and billing system.
• Implemented a standardized upgrade process leveraging SCCM and automation tools, resulting in reduced deployment time
and increased efficiency.
• Analysis on the technical and functional requirements for FHIR (HL7) conversions to X12 files and electronic payments.
• Performed Data Analysis, writing SQL Queries for Testing and Troubleshooting against Data Warehouse.
• Collaborated with the UI designer for creating UI design for the front end and performed logical mapping of data between
back end and front end.
• Worked extensively on EDI transactions 837 and 835 Involved in writing test cases for different LOBs for SIT, Parallel and
UAT
• Validate Limits and Accumulators for correct claim processing and adjustments, review, and update accumulators to plans
that were configured incorrectly.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and
technical requirements within FACETS.
• Worked on creating data flow diagrams and data decomposition diagrams to first identify the architecture for the initiative
and improving code quality (Quality as each microservice has unit, Integration and UI tests) and stored procedures.
• Involved in Data Analysis & Mapping to track all data elements used in the application from the user interface through
different interfaces to the target databases in which they are stored.
• Creating, sizing, grooming, prioritizing, and tracking user stories in TFS.
• Performed user acceptance testing on Jira to validate user requirements and expectations.
• Conducted JAD sessions with management, SME, vendors, users, and other stakeholders for open and pending issues.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271
(Eligibility request/Response), 834 (Enrollment / Dis-enrollment to a health plan)
• Managed the various phases of the Software Development Life Cycle (SDLC) during overall project coordination.
Elaboration
• Served as a Relationship between internal and external business community Claims, Billing, Membership, Customer service,
Healthcare Management, and the project team.
• Assisting the project manager in creating the business case and project plan.
• Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, which include Functional and
Non-Functional specification to hand off to development teams.
Construction
• Recorded requirements in the Requirement Traceability Matrix RTM defined each technical requirement in detail.
Parth Jani
• Analyzed business processes and worked with management and improved and implemented the
solution to ensure compliances.
Transition:
• Assisted in Conducting UAT (User Acceptance Testing) to make sure that all the user requirements are catered to by the
application.
• Involved in preparing a simple and detailed User Manual for the application, for an intended novice user.
Senior Information Technology Business System Analyst
Responsibilities:
• Worked on specifically member enrollment, care connects and claims information system for creating a bridge between
Business owners, stakeholders, and development teams.
• Facilitated Agile Scrum ceremonies (Sprint Planning, Daily Standups, Sprint Reviews, Retrospectives) to drive project
progress.
• Led Agile transformation initiatives, transitioning teams from waterfall to SAFe Agile frameworks.
• Used JIRA to track sprint progress, identify risks, and maintain sprint velocity.
• Worked closely with Product Owners to refine backlog items, ensuring high-priority healthcare compliance features
were delivered.
• Communicated with the User Experience (UX) team and the Development team to capture the data from Microsoft
Dynamics CRM and interface with various MMS.
• Created Business Process Modeling Diagrams/Swim Lane process flows using BPMN notations and MS Visio indicating
transformations and feeds.
• Conducted SWOT analysis for Baptist, helped in identifying new markets and customers.
• Contributed to the build and design of organizational Wiki that provided comprehensive knowledge of workflows,
policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership
management.
• Involved in end-end UAT testing to ensure the accumulators are posted accurately by processing a huge variety of
claims.
• Conducted process mapping to identify current As-Is business processes and To-Be Road map for reengineering the
products.
Education
Bhartiya Shiksha Parishad (BSP)
University of the Potomac
Certificates & Licenses (2)
Professional Scrum Product Owner (PSPO)
https://www.scrum.org/certificates/816499
Professional Scrum Master
https://www.scrum.org/certificates/1014416
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