SUMMARY:

• Over 8+ years as a Sr. Business Analyst within the Health Care domain.
• Expert knowledge in Business Process Flow, Data Analysis and Data Mapping.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans).
• Strong knowledge of Software Development Life Cycle (SDLC - Feasibility Requirements Analysis, Design, Construction, Testing, Implementation, Support) and Rational Unified Process (RUP) and UML methodology.
• Experience with Health Insurance Packaged Application like Facets. Providing US Health Insurance domain and TriZetto's FACETS version and QNXT 3.2 system training and mentoring to other internal Business Analysts and Entry level fresher's including knowledge of conversation from earlier versions of FACETS to version 4.71.
• Works collaboratively with various departments such as Care Management, Member Services, Intake and Enrollment to ensure qualified members are enrolled into the program and receive the appropriate services and care.
• Proficient in creating Business Requirement Documents (BRD), Functional Requirement Specification (FRS) document, User Requirement Specifications (URS) document.
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component, and deployment views to extract business process flow.
• As a part of CMDS, actively involved in Unit Management, Care Management, and Disease Management remediation testing efforts.
• Gathered requirements for automation of referral authorization from CA (Care Advance) to FACETS through UMI (Utilization Management Interface), claim processing from point of entry to finalizing, identifying claims processing problems, their source and providing corresponding solutions.
• Experience with TriZettos FACETS Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Prepared Healthcare Effectiveness Data and Information Set (HEDIS) reporting.
• Knowledge of healthcare standard Health Level Seven (HL7)
• Expertise in the EPIC Medical software application (EMR, EHR) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Proficient in developing and executing Test Plans, SQL queries, performing functional, usability testing and ensuring that the software meets the system requirements.
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Excellent skills in Project and Performance Management to support Strategic Planning, Goal Setting, Strengthen Accountability, Enhance Decision Making, and Improve Customer Service.

TECHNICAL SKILLS:

• Expertise in the EPIC Medical software application (EMR, EHR) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Proficient in developing and executing Test Plans, SQL queries, performing functional, usability testing and ensuring that the software meets the system requirements.
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Excellent skills in Project and Performance Management to support Strategic Planning, Goal Setting, Strengthen Accountability, Enhance Decision Making, and Improve Customer Service.

WORK EXPERIENCE:

Confidential, Atlanta, GA

Sr. Business Analyst

Responsibilities:

• Interviewed Business Users to gather Requirements and analyzed the feasibility of their needs by coordinating with the project manager and technical lead.
• Involved in the analysis of the existing credit card processing system, mapping phase according to functionality and data conversion procedure.
• Works with the corporate HCSC team (similar to healthcare systems like HEDIS) to monitor accuracy of data and methodologies when assigned.
• Worked with diverse team of Business users to gather requirement and prepared BRD and FRD.
• Responsible for development of RMS web application, which manages info of Purchase, Inventory, sales, POS, Accounting & Service modules.
• Involved in analyzing requirements for data migration, data reconciliation, mapping rules, staging rules and transformation rules for the ETL processes.
• Analyzed Business Requirements and Design Specification to gain understanding of Clinical Care Advance, Facets, Macess and CareWebQI application.
• Involved in FACETS Implementation, involved in end-to-end testing of FACETS Billing, Enrollment Claim Processing and Subscriber/Member module.
• Prepared use cases and designed use case diagram, activity diagram and sequence diagram.
• Worked on design and implementation for the Participant Management module of IBM Curam and Data migration from an existing system.
• Conducted JAD sessions with PM, SMEs; facilitated interviews with end users and hospital administrators to collect business requirements.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
• Reviewed patch and hot fix documents, and was involved in testing of patch and hot fix documents me for Clinical Care Advance and CareWebQI during quarter releases.
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.
• Worked as UAT tester for large-scale state sponsored health exchange, receiving employee recognition award for completing UAT testing within required timeframe.
• Worked with DBA to identify and document business rules that are needed to be applied to the Care Management data in the warehouse

Business Analyst

Responsibilities:

• Prepared various documents such as Business Requirement Documents (BRD), General System Design (GSD) and Impact documents.
• Modeled Use Case Diagrams, Activity Diagrams and Data Flow Diagrams using MS Visio.
• Facilitated meeting discussions between business users, business analysts and technical analysts.
• Gathered requirements by conducting meetings and brainstorming sessions with end users and SME and document them using Requisite Pro - the documentation tool offered by Rational.
• Worked within the areas of process improvement and enhancements of Billing/Payment systems for Medicare Part D functional area.
• Analyzed and adjudicated claims using Facets, created workflows using Visio, created macros and queries with MS.
• Served as Salesforce Admin and de-duplicated SFDC tables using DemandTools.
• Worked on receiving Encounter files from their PBM (Pharmacy Benefit Manager), verifying the data content by transactional analysis. Integrated various systems with HEDIS and create design for HEDIS and other systems to pull data in HEDIS.
• Defined Functional Test Cases, documented, and executed test script in Facets system.
• Analyzed various inbound and outbound interfaces to determine the impact of HIPAA 5010 and NPI implementation.
• Gathered, defined and documented highly complex business requirements.
• Managed timely completion of multiple projects in parallel- worked in close conjunction with the Project Management Office (PMO) to define scope of the project and its deliverables.
• Worked with Cognos reporting systems to extract the data for analysis using filters based on the analysis
• Worked on Procedure codes, Provider types, Service types, Specialty codes and Diagnosis codes.
• Worked with technical staff and business users to problem-solve and identify workable solutions.
• Developed workflows that demonstrate current and proposed business requirements.
• Performed requirements modeling and develop analysis diagrams, activity diagrams, sequence diagrams, state diagrams, data models, and use-case realizations using RUP tools in Agile.
• Prioritized the individual workload that involves multiple project assignments and deadlines.

Business Analyst

Responsibilities:

• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Conducted user interviews and documented business and functional requirements.
• Performed Requirement Analysis and developed UML Use Cases, Activity Diagrams using Rational Rose to understand the requirements.
• Worked with the management for improving and giving new ideas for designing future processes of the HIPAA transactions dealing out with EDI'S 271, 276 and 270, 470, 835, 837, 834, HIPAA 4010, 5010, 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 principles and also well versed with ICD10, Facets.
• Completed the documentation of Claims Scenario's for the source system.
• Analyzed the existing claims process and specific business rule logic will be applied in the requirement model.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Created use case scenarios and documented work flow and business process.
• Documented requirements associated change requests with requirements and connected requirements with Use cases.
• Understood the requirements of the Sales and Marketing team.
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time transactions like 270/271/276/277 for Medicare and Medicaid programs in FACETS.
• Performed extensive data modeling to differentiate between the OLTP and Data Warehouse data models.
• Designed the UI of the application, prototyping and wire framing in MS Visio for better illustration of the application.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.
• Evaluated testing results for each potential release build using Test Director, Quality Center and Bugzilla reports, listing summarized bug information in priority sequence, recommended viability of release for production.