SUMMARY:

• Over 8 years of professional leadership experience in Healthcare domain as a Project Manager / Sr. Business Systems Analyst with expertise in analysis, design, development, testing and implementation of business process through software development life cycle (SDLC).
• Business Analyst Experience - 8+ years
• Working in the Healthcare Industry - 8+ years
• IT Development Project Team Experience- 8+ years
• Experience with the Affordable Care- 2+ years
• Experience with Enrollment Transactions- 2+years
• Federal Contract Experience- 2+ years
• Claims transactions - 3+ years
• Workflow Management Systems/Case Management Software Experience- 5 years
• Microsoft Word and Excel- 8+ years
• Help Manage Risk and Dependencies- 8 years
• Detailed understanding of Programs offered by District of Columbia Confidential such as WIC (Women, Infants and Children), MIS/EBT Implementation, Help me Grow, Immunization Information Systems (DOCIIS) and Project Wish.
• Strong knowledge on Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HMO Special Needs Program (HMO SNP), Program for All Inclusive Care for the Elderly (PACE), Managed Long Term Care (MLTC),
• Strong understanding of Health Care Reform, Patient Protection and Affordability Care Act (PPACA) and
• Health Insurance Portability and Accountability Act (HIPAA) standard.
• Good understanding of Health Insurance Exchange (HIX), Electronic Medical Record (EMR) and Electronic
• Health Record (EHR).
• Good knowledge about International Classification of Disease's (ICD9/ICD10) including conversion of HIPPA X12 4010 codes to X12 5010 codes
• Worked on different EDI healthcare transactions like 837 for submitting claims, 835 for payments, 270/271 for health care benefits and eligibility and 276/277 for claims.
• Good knowledge on Medicaid Management Information System (MMIS) for automation.
• Skillful in performing GAP analysis, SWOT analysis, Cost benefit analysis, Risk analysis and User acceptance
• Testing (UAT).
• Experience in conducting Joint Application Development (JAD) and Rapid Application Development (RAD)
• Sessions, Requirement Gathering Sessions (RGS).
• Website requirements gathering for WIC clinic sites for local Agencies
• Interviewed Subject Matter Experts (SME's) for understanding detailed functionality aspects of the business process and carefully transforming information into requirements in an easily comprehensible format.
• Comprehensive knowledge on Waterfall, Rational Unified Process (RUP) and Agile methodologies.
• Hands on experience in analyzing and documenting Business Requirements Document (BRD) and System
• Functional Specifications (SFS) including Use Cases.
• Well experienced in working on MS Word, MS PowerPoint, MS Excel, MS Visio and MS Project.
• Extensive experience in using Unified Modeling Language (UML) tools to create Activity, Sequence, Use
• Case, Class, and Collaboration diagrams.
• Excellent verbal/written communication skills and strong analytical abilities to perform well as an independent and as a team player.
• Proven track record of delivering projects (quality documents/ deliverables) on time.
• Professional with extensive experience in the development, implementation and integration of strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills.
• Exceptional Problem Solving and Sound Decision Making capabilities, along with the ability to resolve difficult situations.
• Creative, aggressive and capable of performing and maintaining positive and productive team environment with integrative thinking skills.

TECHNICAL SKILLS:

Databases: MS Access, EDW, QNXT, CER

Operating Systems: Windows, Mac

Version Control Tools: Rational Clear Case, SharePoint

Defect Tracking Tools: Rational Clear Quest

Business Modeling Tools: Rational Rose, Microsoft Visio, MS Project

Methodologies and Skills: SWOT Analysis, GAP Analysis, Cost Benefit Analysis, Cost Effect Analysis, Agile Development, RUP, UML, SDLCTesting Tools: Rational Test Manager, Clear Quest

PROFESSIONAL EXPERIENCE:

Confidential, Washington, DC

Project Manager/ Sr. Business Analyst

Responsibilities:

• Review and documentation for MIS/ EBT Cost and Feasibility Study.
• Creating project timelines for MIS/EBT WIC implementation
• Analysis on various MIS / EBT Systems such as Crossroads, WOW, QUEST, Hands and conducted a comparison analysis with each systems functional requirements.
• Creation of Data Sharing Agreement with DCDOH and FEMSD (Fire and Emergency Medical Services Department
• Creation of Privacy Agreement with DCDOH and CRISP (Chesapeake Regional information System for Patients).
• Conducting meeting with SME's and Business owners to conduct deep dive requirement sessions for requirement's gathering on all enhancements
• Management of three programs simultaneously including WIC, Project Wish, Help me Grow
• Creating Visio and work flow diagrams for call flows and processes
• Detailed understanding of CARES Application through training
• Created new process for testing by developing Test Cases and managing test results
• Involved in development of policies and procedures for Infant Formula Exchange
• Visiting of local agencies and Service Site to better understand user comfort in using CARES application and how to further enhance various features for the CARES Application to be more user friendly.
• Conducted gap analysis for current DC Food Program banking files as new programs are introduced, help desk call flows and Business Process Modeling; and new requirements for Tele task
• Conducted "As Is" and "To be" processes for Tele task new requirements and Business rules.
• Clear understanding of WIC Banking, ACH Transactions, DC Food program banking.
• Involved in development of prototype for DC Food Program (MS Access) for issuance and redemption files
• Involved in creating a prototype on MS Access for DC Food Programs for the application to create issuance files and record redemption files.
• Conduct walkthroughs with developers and end client for new Infant formula Exchange application created on VB6.
• Creating entity diagrams for BFed DC (Breast feeding) program to capture member information and use for data analytics

Confidential, Worcester, MA

Sr. Business Systems Analyst

Responsibilities:

• Actively involved with SME's (Subject Matter Experts) from different functional areas including legal, finance, clinical coordination, website, medical economics, network development, Utilization Management, Customer Service, Pharmacy, Behavioral Health, Enrollment, Eligibility, Quality, and Compliance etc. to conduct deep dive sessions to gather detailed Business Requirements.
• Team Lead for Provider Relations web development including Provider Tools, Provider Manual and different provider sections for web enhancement.
• Lead the team in analyzing the plans and policies related to HIX.
• Identifying Business Requirements for HMO Special Needs Program (HMO SNP), Program for All-inclusive Care for the Elderly (PACE) and Managed Long Term Care in order to proceed towards a Fully Integrated Duals Advantage program in 2017.
• Detailed understanding of Medicare, Medicaid, Coordination of Benefits and supplemental benefits for HMO SNP and MLTC
• Worked on BI (Business Intelligence) reports reconciliation with the source and target tables.
• Analysis on Care Coordination, transition of Care and identifying process flows for the operations of HMO SNP, PACE and MLTC in collaboration with partnering company, Total again in Place, New York.
• Development of Customer Relations Management (CRM) software using Scrum methodology for marketing and outreach teams in New York in order to track prospective members and outreach activities.
• Created documents such as SIPOC (Suppliers - Inputs - Process - Outputs - Customers), Gap analysis on Medicare services, Coordination of Benefits, Medicaid Services including Medicaid Fee-for-service to identify trigger points for claims, gathering regulatory reporting requirements for state of New York and CMS,
• Assistance in filling for PACE, MLTC, D-SNP application in two-way (State and Fallon Health) and three-way contracts (State, CMS, and Confidential ).
• Involved in Affordable Care Act (ACA) project in identifying detailed process flow for Encounter Data between
• Confidential and EOHHS (Executive Office of Health and Human Services).
• Detailed understanding of ACA Edge Server for Risk Adjustment, Reinsurance and Risk Corridors
• Identifying Business rules and specifications for Enrollment files, Medical Claim Files and Pharmacy files for the ACA Edge Server project.
• Good knowledge about International Classification of Disease's (ICD9/ICD10) including conversion of HIPPA X12 4010 codes to X12 5010 codes
• Data mapping of fields and tables for EDI X12 834 / 837 files with in-house database. Monitored issues and change requests related to EDI transactions.
• Conducting impact assessment sessions with project team to identify impacted functional areas
• Creating Business Requirements Document and Technical Design Document and obtain approval
• Data mapping for Edge Server file such as 834 / 837 to identify fields and tables from EDW (Electronic Data
• Warehouse) and databases
• Developing workflows to identify various processing including error files and resolutions within the department.
• Worked on development of Product Creation System with Pega Software in order to Data map Benefits within
• QNXT (Trizetto Core Administrative System) and EDW.
• Coordinated work for the implementation of a new company with the introduction of a new product,
• Fallon Total Care, a duals program with a three-way contract with the State of Massachusetts, Center of
• Medicare Services and Confidential
• Gathering website requirements for Fallon Total Care from various departments and regulatory requirements
• Gathering business requirement of Duals project with the State of Massachusetts, Virginia and New York
• Conduct SWOT Analysis, cost benefit analysis, Software Development Life Cycle
• Coordination and support towards the project during its testing phase and UAT
• Use of Technical tools such as QNXT, MS Access, Microsoft Visio, Excel, MS Project.

Environment: MS Visio, MS-Project, Windows, SQL, UML

Confidential, Wellesley, MA

Sr. Business Analyst

Responsibilities:

• Conducted detailed and comprehensive Business Analysis by working with end users and other stake holders to identify the system, operational requirements, and proposed enhancements.
• Facilitated Joint Application Development (JAD) sessions with all IT group members for communicating &
• Managing expectations.
• Discussed various means for integrations with current system using an adoption through execution strategy and prototyping.
• Gathered business requirements from business users such as Insurance Policy Managers, credit card
• Managers and drafted Business Requirement Specification (BRS).
• Identified all necessary Business and System Use Cases from requirements, created UML diagrams including
• Use Case Diagrams, Activity Diagrams, and Sequence Diagrams using Microsoft Visio.
• Worked on transfer of electronic healthcare information.
• Led a team and was responsible for work allocation, tracking using MS Project, periodic reporting and delivering quality product to the client.
• Assisted in developing test scenarios, test scripts and test data to support unit and system integration testing.
• Used Requisite Pro to manage schedules and collaborate with different teams
• Create and update tasks in the MS Project for the senior management reviews.
• Assisted in the development of training materials for new technology and process improvements.
• Involved in comprehensive testing of the system to check it satisfies functional specifications.

Environment: MS Visio, Rational Requisite Pro, SQL, MS Office, MS-Project, Windows

Confidential, Buffalo, NY

Business Analyst

Responsibilities:

• Analyzed current business process flow by understanding preset business rules and conditions through requirement gathering.
• Addressed all aspects of the claim processing lifecycle, starting from identifying a claim right up to closure.
• Established a business Analysis methodology around the Rational Unified Process.
• Conducted formal interviews, Live Meetings and JAD sessions with business users Subject Matter Experts (SME's)
• Gap Analysis: Analyzed the client's applications programs to determine the impact of the HIPAA final rule on
• EDI Transaction Set and Code List implementation.
• Defined the changes to bring the affected systems into HIPAA compliance.
• Worked with FACETS Team for Claims Validation and Verification Process.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Documented, organized and tracked the requirements using Rational Requisite Pro.
• Defined project milestones, schedules, and monitored progress using MS-Project and updated plans as required.
• Assisted with user testing of systems and maintained quality procedures and ensured appropriate documentation.
• Worked on different EDI healthcare transactions like 837 for submitting claims, 835 for payments, 270/271 for health care benefits and eligibility, 276/277 for claims.
• Provided key input in working with users in defining project and system requirements.
• Claim validation and Pending/Denied Claims Analysis for the Health plans Medicaid programs.
• Worked closely with the technical team to look up for the best possible solution on requirements by keeping business needs and technical constraints in mind.
• Involved in UAT with the SME's to ensure final product reflects all business rules and meets all requirements.

Environment: UML, MS Word, MS Visio, Rational RequisitePro, Rational Clear Quest, Quality Center, SQL