SUMMARY:

• Qualified professional with 7 years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Claims subject - matter expert (SME) with detailed noledge of claims processing.
• Good Knowledge of HIPAA Compliance Lifecycle, HIPAA Insurance Regulations.
• Experience in Change Management Process & gap analysis (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Good noledge of Health Insurance Plans and experienced in determining the FACETS Eligibility, Claims, Billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience with medical management data such as Utilization Management (UM), Case Management (CM) and Disease Management (DM) and skills to support data profiling.
• Experience with HIPAA 4010 & 5010 EDI healthcare transactions like 837, 835, 834, 820, 270, 271, 276, 277, and 278, NPI,ICD9,ICD10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Extensive experience in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from a Operational Data Store to a Enterprise Data Warehouse.
• Worked on different NPS applications like HIQK, HEHK (EEC), HURK, HSSK, HRBK, etc.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Experience designing and developing SQL statements and queries for Oracle Sybase, Toad and SQL Server 2000 database.
• Extensive noledge of NPS Applications: BFA/BFM Benefit File Tool, HRBK-Benefit File Coding
• Knowledge in the ETL (Extract, Transform and Load) of data into a data ware house/date mart and Business Intelligence (BI) tools like Business Objects Modules (Reporter, Supervisor, Designer, and Web Intelligence).
• Experienced in conducting requirement analysis, use case design, designing test plans and developed database schemas based on the logical models.
• Extensive experience in conducting Joint Application Development (JAD) sessions.
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio, technical assessment tools, Data Warehousing concepts and web design and development.
• Certified in SAS, Six Sigma, Lean Manufacturing and Industrial Ergonomics.
• Solid Experience in developing Scope/Vision Documentation and Project Plan.
• Strong experience in Client interaction and understanding business applications, business data flow and data relations for them.
• Highly motivated, result oriented professional with a short learning curve and strong communication skills.

TECHNICAL SKILLS:

Tools: Microsoft Office Suite (Word, Excel, Power Point, Project, Access), Outlook, Microsoft Sharepoint, ADR, HIPAA Suite, Trizetto Facets, IBM Lotus Notes, Web server Internet Information Server (IIS), HP Service Desk (HPSD)

Analysis Tools: Requirement Solution Analysis (RSA), Data Analysis, Data Modeling, Logical and Physical Database Design, ETL Analysis, RUP, UML, Object Oriented Analysis, Rational Rose, ERWin, Visio, Rational Requisite Pro, Dashboard Design, BRM

Testing Tools: Mercury Quality Center, Mercury TestDirector

Reporting Tools: Cognos, Crystal Reports, Business Objects, Xcelsius

Database: SQL Server 2000, SQL Script,Oracle, Teradata, MS-Access

Data Access Technologies: IBM Datastage, PL/SQL, Toad, MQ Series, ADO, ODBC, SOAP, Stored Procedures, Informatica Power Center

WORK EXPERIENCE:

Confidential, Chicago, IL

Sr. Business System Analyst

Responsibilities:

• Gather detailed business and technical requirements and participate in the definitions of business rules and data standards by using Rational Rose, Visio and Requisite pro - RUP
• Collaborates with IT and Business performing data profiling effort for building new Enterprise Data Warehouseacross all subject areas such as Claims, Member, Provider, Benefits, Employer/Group and Code Sets to meet analytic needs of business users for new Enterprise Data Warehouse
• Conducted extensive Joint Application Development (JAD) sessions for all business related issues.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Mapping analysis ofICD9 -ICD10Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Managed Scope and change throughout the SDLC process of the product.
• Analyzed 5010 EDI healthcare transactions like 837, 835, 834, 820, 270, 271, 276, 277, and 278, along with NPI,ICD10, NDC, DRG, CPT, and NCPDP codes.
• Performed detailed system analysis on source tables and fields spanning across multiple subject areas
• Interfaced with the Program Office BFM team to verify chargeable travel numbers and ensures that funding is available for personnel to travel.
• MappedICD9 - ICD10 data for application development.
• Provided support withICD10support for product deployment.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to Providers, payers, subscribers and other related entities.
• Performed analysis on enterprise data/report integration & provided functional specification to development team to build Enterprise Reporting Systems.
• Help in preparing the material of the providers and insurance companies using the software supportingICD10.
• Collaborated with both business and IT to provide historical data for financial enhancements and Federal government processes.Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements
• Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
• Created source to target mapping documents/data flow diagrams used by developers and data modeling team determining business logic and use for transformation rules
• Map all attributes from source system to ODS and finally to EDW.
• Developed test strategy and test scenarios used during QA testing throughout the SDLC addressing performance, data issues, identifying and tracking defects. Assisted with SIT, UAT testing and fact dimension modeling as needed.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Assess current healthcare payer processing activities
• Working noledge of implementing software development projects using methodologies such as Waterfall, RUP, and Agile Scrum.

  Defined Functional Test Cases, documented, Executed test script inFacetssystem.

• Conducted analysis of HIPAA compliance and took part in discussions for designing the healthcare transactions to be HIPAA 5010 compliant.
• Assisted Project Management in developing Scope/ Vision Documentation and Project Plan, tracking project process, and developed Risk Mitigation Plan
• WorkedwithClaims, enrolment, eligibility verification for members and providers, benefits setup, and backend payment cycle infacets.
• Educate and offer recommendations according to current industry business analytics
• Manage assignments and deliverables according to plan
• Mentor and support project team members
• Post implementation support

Environment: RUP, UML, UAT, SDLC, SOA, Rational Rose, DataStage, COGNOS, Oracle SQL Developer, SQL TOAD, SQL Server, ODS, EDW, ERWIN, Visio, MS Access, MS Office 2011, Rational Requisite Pro, Rational Clear Case, Clear Quest, UNIX, Oracle, PL/SQL, DOS, Agile, Waterfall, Paradigm, Hedis, DEV, QA, PROD, XML File, Flat Flie

Confidential

System Analyst

Responsibilities:

• Gatheird, compiled and analyzed medical benefits data. Prepared client's monthly reports on, large claims and monthly payments financial profile.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Develop business/technical requirements and test case preparation for system enhancements.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Involved in GEM (General Equivalence Mapping) tools for forward mapping ofICD9 -ICD10codes.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Interacted with business heads & SME’s to finalize the Business Requirements for the application.
• Performed extensive requirement analysis including Data analysis and Gap analysis.
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• HIPAA Conversion Analysis - Involved in the documentation of HIPAA 5010 changes to EDI (X12) 837,834,820, 835,999, 276, 277 Transactions.
• Wrote SQL queries for each Test case and executed in SQL Plus to validate the data between Enterprise Data Warehousing and Data Mart Staging Tables.
• Monitored process and implementation ofICD-10analysis.
• Worked withBusinessSME's and IT staff to identify and translateICDbusinessrules intosystemrequirements.
• Performed Gap Analysis betweenICD9 andICD10.
• Written SQL queries to verify data quality and the code logics implemented as requested.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principals.
• Produced functional decomposition and logical models into an enterprise data model.
• Assists with strategies, medical benefits, pharmacy benefits with upper management to improve our Private Insurance HealthCare Exchange products.
• Defined an approach to perform forward mapping and backward mapping fromICD9 to anICD10 code and fromICD10toICD9.
• Worked closely with various teams -, Provider File Maintenance, GENO File Maintenance, Benefit File etc., to ensure projects are completed successfully.
• Used various NPS applications like HIQK for claims inquiry, HEHK for adjudicating and testing claims, HURK for accessing specifications, HRBK to browse through the Benefit File, HSSK to download claims from Production to Model Office, etc.
• Member of the APM Eligibility service team, providing support to the financial and benefit code process.
• Managed changing requirements which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Gatheird information from manuals to understand the changes and differences inICD9 andICD10and created requirement documents for the coders.
• Extensively worked on theICDcode conversion fromICD9 toICD10, assisting and leading various teams by complying with already going works in the health care domain and work with the conversion of HIPAA .
• Developed & executed several Optimized queries in SQL
• Performed Unit Testing, SIT and User Acceptance Testing and documented detailed defects.
• Wrote test cases and test scripts for the User Acceptance Testing
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Create business rules and did analysis to improve and support current sales compensation system by consolidating different systems to one system and add new business value to current system.
• Streamlining the commission calculation system and add business value by analysis of agent demographics and members information.
• Managed various tests, stored test information, reviewed and analyzed test results.
• Used MS Access defect tracker tool for defect management
• Queried database using SQL for backend testing

Environment: RUP, UML, UAT, SDLC, SOA, Rational Rose, Informatica Power Center, MicroStrategy, Oracle SQL Developer, COGNOS, SQL TOAD, ERWIN, Visio, MS Access, MS Office 2011, UNIX, Oracle, PL/SQL, DOS, Agile, Waterfall, NASCO, DB2

Confidential, New York City

Business Analyst

Responsibilities:

• Complete ownership of Medical Claims, Revenue subject areas.
• Creation of FACT, Dimension (DIM) table structures based on business rules which included 125+ tables, 1000+ data elements
• Data population logic, temporary tables, ETL extraction logic, data interaction, incoming & outgoing data flow rules within multiple datamarts, datawarehouses.
• Gap analysis of data requirements between source and target system
• Identification of business rules for data transformation and bridging the gaps.
• Accepted inbound /outbound EDI (X12) 837,834,820, 835, 999, 276, 277(Claims, Provider, Portal, Billing, Benefits) transactions from multiple sources.
• Responsible for integratingwithFacets.Designing test scripts for testing of Claims in Development, Integration and production environment.
• Involved in projects including Enterprise Data Warehouse (EDW) infrastructure, Data acquisitions, Data migration,Business Objectsexecutive dashboards, OLAP cubes, Data work flows documentation, Metadata repository management.
• Developed executed several Optimized queries in SQL on this data.
• Developed reporting specifications by identifying business needs, prototyping sample reports and mapping data elements from reports to data models.
• Developed Use cases and Activity process flow diagrams using MS Visio for the FACETS Enrollment Process.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD10Code set and ANSI X12 5010 formats.
• Generated server side SQL scripts for data manipulation and validation and created various Snapshots and materialized views for remote instances.
• Worked with various ETL tools for the generation of data marts for reporting purpose. Worked with XML feeds from multiple sources systems and loaded the same into Enterprise data warehouse.
• Design of extract file format, column fields to be included, primary keys, grouping keys, indexes.
• Creation of business rules for grouping logic for extract files, data flow logic.
• Business rules were implemented using rules engine. Rules were easily handled, modified and quick checks of possible scenarios were done. Easily understandable by development team also.
• Responsible working on Sybaseand SQL Server Database analysis, design and development skills, including extensive Shell scripting and stored procedures.
• Traced requirements using traceability matrix and created test cases to test the requirements. Performed UAT testing billing and invoice on facets.
• Creation of Business Requirement Document (BRD), high level design document (HLD, FRS) giving the in depth functional details, ETL logic, business rules in detail.
• Following various HIPAA, NCPDP guidelines in all projects.
• System testing, analysis support in defect fixing, regression testing, troubleshooting on servers, debugging through source code for defect analysis.
• Testing done in System Integration Test Environment, Preprod environments.
• Create, review business UAT test scenarios with business end users.
• Defined Functional Test Cases, documented, Executed test script inFacetssystem.
• Execute UAT test scenarios, co-ordinate with IT for executing those for all subject areas.
• Educating business users about the data arrangement, new report structures in target system.

Environment: RUP, MS Word, Excel, PowerPoint, Project, Visio, SharePoint, ADR, Oracle, SQL,SQL Script, IBM Datastage, ETL, EDI, Mercury TestDirector, Mercury Quality Center.

Confidential, Chicago, IL

Business Analyst

Responsibilities:

• Analyzed existing reports and defined business requirements and business process flows
• Conducted JAD sessions with PM, SMEs; facilitated interviews with end users and hospital administrators to collect business requirements
• Built a business process model using Rational Rose and Visio.
• Gather detailed business and technical requirements and participate in the definitions of business rules and data standards.
• Facilitated SME interviews and assisted in identifying and analyzing the possible technical solutions.
• Performed requirement analysis, went through use cases according to the flow of patient data and rules of security sharing.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Formulated logical statements of business requirements researched and evaluated alternative solutions and recommend the most efficient solution for system design.
• Participate in business systems planning for integrated analytic needs; participate in defining approaches and priorities for satisfying needs.
• Aided management in standardizing web applications by preparing GUI standards and recommending alternatives for in corporation in a phased, iterative manner.
• Was responsible for Prior Authorization & Treatment Authorization Request forms.
• Assisted in data mart design and prototyping
• Designed and Administered Teradata Scripts, Tables, Indices and Database Objects
• Assisted in designing and validating source target mappings and transformation logical data model required to support information requirements.
• Tracked and documented defects and communicated them to the technical developers.
• Used Test Director for bug and defect tracking.
• Assisted the project manager in preparing the project schedules, milestone tracking, resource allocation using Microsoft project.
• Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
• Worked extensively with the QA team for designing Test Plan and Test Cases for the User Acceptance Testing.
• Involved in manual testing and UAT with the development team and QA team.

Environment: MS Office, MS Excel, MS Access, Business Objects, Crystal Reports, TSO/ISPF, XML, SQL,Oracle Pl/SQL, HTML, MS Visio, RUP 2002, Rational Rose 2002, Rational Clear Quest 2002, Rational Requisite Pro.