SUMMARY:

• Facilitator between Business Systems and Information Technology with over 6 years of extensive experience in the field of EDI Analysis.
• Worked on Welfare to Work (WTW), CalFresh (formally known as Food Stamp), CalWorks and Medi - Cal
• Knowledge in California HealthcareEligibility Enrollment, and Retention Systems (CalHEERS)
• Experience in gathering business and application requirements, Business Processes, identifying risks, Impact analysis, UML modeling, Sequence and Activity Diagrams using Rational Rose and Visio.
• Experience in writing Business Requirements Documents (BRD), Functional Requirement Documents (FRD), System Requirement Specifications (SRS), and Non-Functional Requirement Documents (NFRD).
• Several years of experience and advance knowledge of the Systems Development Life Cycle (SDLC), Waterfall, Agile, Rapid Application Development (RAD), Rational Unified Process (RUP).
• Expertise in Rational Unified Process (RUP) methodology, Use Cases, Software Development Life Cycle (SDLC) processes and Object Oriented Design Technologies.
• Active role in eliciting requirements from users by utilizing methods like Interviews, Requirement workshops, Joint Application Development(JAD) and Participatory Design
• Performed User Acceptance Testing (UAT) and created test scenarios
• Developed test cases, prepared test data and manual automated test
• Efficient and proven track record with handling Change Requests by the Clients
• Knowledge in Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277 and ICD9 / ICD10.
• Knowledge in Medical Management Information Systems (MMIS), Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process
• Knowledge of Electronic Medical Record ( EMR ) and Electronic Health Record(EHR)
• In House experience with HIPAA/EDI Medical Claims analysis, design, implementation, and documentation.
• Knowledge in Health Insurance Plans (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans. Excellent knowledge of HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding
• A motivated, committed, quick learning, detail-oriented team player with good communication, analytical, leadership, interpersonal and problem solving skill

TECHNICAL SKILLS:

Operating Systems: Windows/XP/Vista/ Mac/Linux/SunSolarix/HPUX

Industry Standards: HIPAA, SOX, ISO, Six Sigma, CMM

Databases: Oracle, MS SQL server, MS Access, IBM DB2

Tools: MS Office: Word, Excel, Access, Power point, Project, Visio, Front Office, Rational Rose, SoDA, Software Modeler, Team Test, Clear case, Clear Quest, Load Runner, Business Modeler, MMIS

PROFESSIONAL EXPERIENCE:

Confidential, CA

EDI Analyst

Responsibilities:

• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in Rational Rose for the Business Use Case and System Use Case.
• Knowledge on California Healthcare Eligibility Enrollment, and Retention Systems (CalHEERS)
• Worked on Welfare to Work (WTW), CalFresh (formally known as Food Stamp), and Medi-Cal
• Defined use cases for CalWin Eligibility Enrollment process.
• Gathered requirements and prepared Project Charter, Business Requirement Documents (BRD), Function Business Requirement.
• Knowledge on California Healthcare Eligibility Enrollment, and Retention Systems (CalHEERS)
• Documented the Business Process Flows, Business Use Cases, System Use Case and Use Case Realization following the Rational Unified Process (RUP) methodology.
• Tagged and traced the created artifacts (Business Use Cases, System Use Case, Business Rules and Use Case Realization) in Requisite Pro, making requirements available to all team members.
• Maintained Requirements Traceability Matrix in Rational Requisite Pro and used Clear Quest to manage change requests and track defects.
• Created documents like the Business Glossary to facilitate the other teams in understanding client business in Requisite Pro.
• Involved in creating User Acceptance Criteria and Testing
• Used Microsoft SharePoint to manage the documents and have version control.
• Analyzed the business requirements for Welfare to Workdetermining the eligibility for Enrollment.
• Ensure Medi-Cal products are operationally ready prior to deployment by driving establishment of Checklist Process Flows
• Participated in Regression testing and monitored bugs on day to day basis
• Reported bugs using Test Director tracking tool and worked closely with the developers

Environment: UML, RUP, Rational Requisite Pro, Rational Clear Quest, Test Planning and Defect Resolution

EDI Analyst

Responsibilities:

• Gathered requirements and prepared Project Charter, Business Requirement Documents (BRD), System Requirement Specification (SRS) by interviewing Business Users/SME’s
• Used Requisite Pro for writing/analyzing project vision, goals, specifications and requirements.
• Conducted Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in Rational Rose for the Business Use Case and System Use Case.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA5010 transaction processing EDI’s 837,835, 270, and 271.
• Analyzed HIPAA 5010 related to 837,835, 270, and 271 transactions and performed gap analysis between the 4010 and 5010.
• Defined use cases for Claims and Enrollment process.
• Documented the Business Process Flows, Business Use Cases, System Use Case, Business Rules and Use Case Realization following the Rational Unified Process (RUP) methodology.
• Tagged and traced the created artifacts (Business Use Cases, System Use Case, Business Rules and Use Case Realization) in Requisite Pro, making requirements available to all team members.
• Maintained Requirements Traceability Matrix in Rational Requisite Pro and used Clear Quest to manage change requests and track defects.
• Analyze EDI - X12 data elements captured by the existing system to validate it against the data elements required for new system.
• Worked on configuration of Facets with Enrollment and Claim processing.
• Created documents like the Business Glossary to facilitate the other teams in understanding client business in Requisite Pro.
• Used Microsoft SharePoint to manage the documents and have version control.
• Analyzed the business requirements for Medicare claims Part A, B, C and D determining the membership eligibility for Enrollment.
• Ensure Medicare Part D products are operationally ready prior to deployment by driving establishment of Checklist, Process Flows and Training Document
• Monitor CMS communication and industry trends in Medicare Part D
• Adhered data transition of the payment and remittance advice as per the EDI standard 835.
• Worked on different EDI scenarios for batch processing.
• Worked on HL7 framework for the exchange, integration, sharing and retrieval of electronic health information
• Performed Integration and System Testing by executing the steps for test plan
• Ability to work within an integrated test team and communicate the status of testing to QA test lead

Environment: RUP, Rational Requisite Pro, Rational Clear Quest, Excel, UML, HP Quality Center

EDI Analyst

Responsibilities:

• Gathered requirements by conducting meetings and brainstorming sessions with end users and Subject Matter Experts (SMEs) and documented them using Requisite Pro.
• Worked on implementation of ICD-10 require significant changes to clinical and administrative systems that capture and report diagnosis codes, practices will need system changes for updating the HIPAA transactions from version 4010 to 5010
• Involved in updating what sets ICD-10 apart from ICD-9 specificity that convey more detail than the old codes and payer will expect the professionals to bill using more specific codes
• Prepared Business Requirement Documents (BRDs) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Performed Gap Analysis of the processes to identify and validate requirements.
• Responsible for architecting integrated HIPAA, Medicare solutions
• Defined and analyzed test cases, test scripts, bugs, interacted with QA/ development teams in fixing errors and conducted User Acceptance Test (UAT).
• Created Business requirement document (BRD), Functional Requirement Specification (FRS), Technical Requirement Specification for application development following the Agile methodology.
• Assisted the Readiness Project Manager in preparing and delivering presentations to management and other interested parties
• Apply UML notations and methodology in developing models that accurately represent the business process and workflows and clearly communicate them to the stakeholders.
• Conducted JAD sessions involving the management, development and user teams for clarifying requirements and facilitating better communication.
• Coordinated and prioritized outstanding defects and enhancement/system requests based on business requirements, allowing sufficient time frame to ensure accuracy and consider deadlines
• Reviewed Test Plans developed by the testing team for testing the application.
• Worked on health claim medical Provider codes Current Procedural Terminology or Health Common Procedure Coding that are assigned to particular units of medical treatment
• Worked on ED 835 Electronic Remittance provides information for the payee regarding claims in the final status including information about the payee and payer
• Involved in performing version control and defect tracking activities using Rational Clear Case and Rational Clear Quest.
• Coordinated the business associate of the self-funded health plan by providing administrative services for the plan and must provide assurance that safeguard and limit the use and disclosure to protected health information
• Worked on Administrative Service Only (ASO) to evaluate and process claims under the health plan while maintaining the responsibility to pay the claims.

Environment: Windows, Rational Requisite pro, Clear Case, Rational Rose, Clear Quest, UML

EDI Analyst

Responsibilities:

• Understood the Business Logic, User Requirements & developed Design & User Interface Specifications.
• Involved in Joint Session meetings with Technical lead to develop a maintenance process plan and documented a dynamic Requirements Traceability Matrix.
• Validated the compliance of new Requirements with the Security Rule in HIPAA, documented many Change Request and Enhancement Request Reports using Clear Case for approval from Project lead.
• With consent of business units and technical leads, drafted the new Business Requirement Document and System Requirement Specification for the Maintenance process.
• Generated simplified Business and System use cases to ensure high degree of compliance with Business Requirement Document.
• Carried out a dynamic Gap analysis to determine the proficiency of the new process plan in comparison to the old one, as well as conformance to the requirements.
• Worked on Health care Provider to maintain members Protected Health Information strictly confidential in compliance with Health Insurance Portability and Accountability Act
• Implemented an incremental maintenance process plan to enable user acceptance testing on the go.
• Involved on EDI 835 claim payments made based on NPI and Tax ID number on reimbursement arrangement and multiple providers may be paid under the group

Environment: Windows, SQL Server, Clear Quest, Clear Case, Cognos, Informatica, MS Office, MS Visio, MS Project, Requisite Pro

Business Analyst

Responsibilities:

• Participated in structuring, underwriting and documentation of credit facilities.
• Ability to analyze data to understand trends and utilize to develop business solutions
• Authored Business Requirement Document (BRD) for development of software to support Black & Scholes Model, CAPM, and Sharpe Ratio for investment decisions, in keeping with risk regulations that were in place.
• Developed models to determine the effects of possible mergers with other banks.
• Conducted JAD sessions with merger and acquisition (M&A) SMEs, the management of charter one, and research and management teams of other banks.
• Introduced banking procedures to business analysts and other members of merged entity.
• Performed data analysis and gap analysis to keep projects on track.
• Demonstrate SOX compliance with the regulation the actual department its financial reporting process the risk process
• Worked on Business Intelligence (BI) large amount of information to help identify and developed new opportunities
• Worked on Business Process Management (BPM) software enable to create, deploy and monitor automated and semi-automated business process
• Collaboratively with business representatives, Project Management and varied IS teams to develop and implement the specific technology and architecture necessary to deliver business solutions
• Ability to perform queries for data analytics to assist in formation of requirements, solutions and issue resolution.

Environment: MS SQL Server, Informatica Power center, Mercury Quality Center, MS Word, MS Excel, Clear Quest, Clear Case

ISO Internal Auditor

Responsibilities:

• Updated current and created new policy and procedures in compliance with ISO.
• Managed all related internal audit programs and issued corrective actions.
• Served as the designated Management Representative and liaison to 3rd party auditors.
• Provided recommendations for business process and internal control improvements
• Ensured compliance with applicable ISO laws and regulations
• Performed audit procedures, including identifying and defining issues, developing criteria reviewing and analyzing evidence and documenting procedures.
• Reviewed and updates Material Safety Data Sheet (MSDS)
• Six Sigma identifies problems in a process, set up project with in the process; evaluate the process works through the project.