SUMMARY:

• Eight years of Experience as a Business Analyst in Health Care domain on various areas like Claims Processing, Billing, Insurance and Reimbursement, Medicaid and Medicare Services, and Pharmacy Benefits Management.
• Experience in Mapping ICD 9 codes with corresponding ICD 10 Diagnosis and Procedure Codes.
• Worked with different Business Areas like Claims and Enrollment to document proposed ICD 9 - 10 Code changes.
• Having extensive domain knowledge ­in MMIS, EPIC, EDI X12,HL7,HIPAA, ICD-10, system, Medicare and Medicaid, CMS Compliances/Regulations.
• Knowledge on claims process and adjudication in the Medicare Part A, B, C and D, Medicaid, Managed care, Private and TPA Insurance Sectors.
• Performed 5010 Upgrade mapping for new B2B and existing B2B clients.
• Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR(continuity of Care Record), CCD(Continuity of Care Document),NCPDP Script, ELINCS, and CDA, HHS, CMS, RHIO's, IHDN's.
• Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Designed and developed normalized, relational databases in MySQL.
• Experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.,) HL7, Eligibility and Benefit systems, ICD-10, HCPCS, CPT, HIPAA 4010 and 5010,Claims Adjudication and expert in Affordable Care Act( ACA), aka Healthcare Reform (HCR).
• Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820 Companion guides.
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Expert in compliance with HIPAA 4010 and 5010 standard.
• Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements.
• Strong experience with different project methodologies including Agile-Scrum Methodology, Waterfall, Modified-Waterfall, Iterative, Incremental and RUP.
• Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834 (Benefit Enrollment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820 (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response)
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.
• Strong Management and Communication Skills, demonstrated proficiency in leading and mentoring individuals to maximize levels of productivity, while forming cohesive team environments.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.
• Defect Management / Bug Fixing - Fully involved in the process of defect identification and resolution using tools like QTP, Clear Quest, and Quality Center.
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking
• Familiar with PMI PMBOK and IIBA BABOK, Experienced in training and mentoring team members with product knowledge and business processes.

TECHNICAL SKILLS:

Standards & Methodologies: HIPAA, CMM, Six Sigma, SDLC, RUP, Waterfall, Iterative, Incremental, Agile-Scrum Methodology, CPT and ICD-9 Coding, ANSI X12

Project Management: Microsoft Project and Microsoft Office

Modeling Tools: Rational Rose, Microsoft Visio

Change Management Tools: Rational Requisite Pro, Clear Quest, Clear Case, SharePoint

Testing Tools: Rational Enterprise Suite, Quality Center, Win Runner, Load Runner

RDBMS and Databases: Oracle, MS SQL Server, MS-Access, Sybase

Operating Systems: Windows, Familiar with UNIX and LINUX

Statistical Tools: SAS

PROFESSIONAL EXPERIENCE:

Confidential, Chicago, IL

Sr. Business Analyst

Responsibilities:

• Responsible to insure that EDI Process is HIPAA (Health Insurance portability and Accountability) compliant and worked on ANSI X12 standards
• Participated in CA-MMIS (California - Medicaid Management Information System) knowledge transfer in preparation for Implementation and Operation of the ICD 10 enhancement.
• Serving as a lead for requirements team and subject matter expertise (SME) with healthcare systems.
• Worked closely with the customer to detail and convert business requirements into system and operations requirements while working with external partners to complete the design, development and implementation of the requirements.
• Addressed requirements work as a liaison among stakeholders in order to elicit, analyze, communicate, and validate requirements and business processes.
• Leaded the development of Business Requirements Documentation (BRD) for analysis related to the ICD 10 mandate.
• Used the Agile-Scrum Methodologies for the Software Development Life Cycle (SDLC)
• Participated in CA-MMIS (California - Medicaid Management Information System) knowledge transfer in preparation for Implementation and Operation of the enhancement.
• Configured and updated hospital, ancillary and professional agreements in Facets using NetworX pricer.
• Performed extensive testing of all configuration and updates.
• Instrumental in ensuring conversion from old system to Facets did not disrupt claim payments.
• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Involved in FACETS Implementation, FACETS billing, enrollment, and Claim Processing and Subscriber/Membership module.
• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Worked on Member Management, Eligibility, Claims and Billing modules within FACETS.
• Design, build and test Facets configuration in support of business requirements
• Configure Facets modules based on the design approach
• Involved in Facets Configuration to make sure all information will be sent without any error
• Involved in Trizetto Facets System Administration, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development
• Evaluated and performed testing within Facets for Rejected QA Scenarios.
• Designed and developed web pages to explain the requirement for technical team using XML.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Create test data as required by tests in Facets
• Develop Business Requirements for all 5010 EDI transactions: 270, 271, 278, 834, 835, 837i/o, and 837d
• Involved in Claim Processing from End to End and major work was involved with 837 P/I Claims Processing systems and 834 benefit enrollment
• Provide analyst support during all phases of the Software Development Life Cycle including development and testing (unit/system) phases
• Worked on SQL queries and PL/SQL stored procedures for QA testing and data validation of Metric Reports.

Environment: Windows 7, SQL Server, MS Visio, HIX, QNXT, MS Office, Agile, Clear Case, Clear Quest, Rational Quality Manager, CHDP Systems, CMIS, CRM, Oracle, .NET, XML.

Confidential, Waukegan, IL

Sr. Business Analyst

Responsibilities:

• Facilitated JAD sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system.
• Responsible for creating working document to document provider agreement information.
• Responsible for gathering and documenting Participating Specialist, Ancillary & Hospital providers.
• Responsible for gathering providers agreements.
• Responsible for verifying current provider agreement information.
• Responsible for creating Specialist, Ancillary & Hospital agreements in Facets.
• Responsible for documenting testing scenarios.
• Responsible for resolving failed claim test.
• Responsible for documenting progress and ensuring all provider agreements were created.
• Key resource for Facets questions.
• Provide analyst support during all phases of the Software Development Life Cycle including development and testing (unit/system) phases
• Maintain test data files and monitor system configuration to ensure data integrity; review data loaded and processed to identify gaps and data anomalies
• I was responsible to analysis of the proposed system and prepare the gap analysis document and functional design documents.
• Extensively involved and performed Feasibility Analysis for the proposal of the new system around agile methodology
• Benefit and contract Administration
• Modified configuration errors in order for adjustments and processing
• Develop, coordinate and support Information Technology Division on all operational requirements of FACETS claims processing system and production management.
• Performed Quality Assurance of new or existing contracts and configuration to ensure appropriate or correct payment was made via unit testing.
• Created and modified queries utilizing Facets data tables
• Involved in developing database objects using FACETS database in both SQL Server and Sybase environments.
• Develop, design & implement department plan to operationalize new FACETS integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
• Worked closely with stakeholders and SME’s for requirements gathering.
• Created EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors
• Identified end to end requirements for all systems and business units that may be impacted by the project.
• Conduct design meetings with data architects to review and update internal data models for clinical data warehouse
• Conducted client requirement gathering sessions to leverage web service APIs
• Developed requirements integrating Use Case diagrams and designed the testing process flows.
• Followed the RUP methodology for the entire SDLC.
• Conducted walkthrough and lead work sessions.
• Documented and tracked all product defects with use of SQL (reporting).
• Developed tables, Views, Stored Procedures and Triggers using SQL Scripting
• Writing Complex SQL queries and optimizing SQL Queries
• Using MS-Visio analyzed business requirements and process through Use Cases, Class, Sequence, and Activity diagrams, and adapted UML standards to define modularized Data Process Models.
• Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
• Developed a Business Acceptance testing strategy and plan.
• Created test files and analyzed test results using MS-Excel.
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Coordinated and facilitated the execution of User Acceptance testing.
• Conducted Business Process (As Is/To Be) sessions with various department directors and staff to ensure the Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program covered all identified new and changed processes.
• Gathered requirements for impacted system and business areas for ICD-10 and their needs to embrace the changes

Environment: Trizetto, Facets, SQL, HIX, QNXT, UML, JAD/RAD, ECMS, MS Visio, J2EE, Cognos, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), Oracle, Rational RequisitePro, Web Based Application (IIS)

Confidential, Saint Charles, MD

EDI Analyst/Business Analyst

Responsibilities:

• Built an Information Security Risk Assessment (ISRA) for the secure exchange of health insurance data as part of the Affordable Care Act (ACA).
• Responsible for implementing payers onto the Health Care Exchange (HIX) for the Affordable Care Act.
• Strong working knowledge of the 834, 837 & 835 EDI Healthcare files and Transactions.
• Thorough knowledge of ICD-10 codes and CPT codes for both Mental and Medical Health and worked extensively with Inbound and outbound 834 Transactions processing systems.
• Compile, validate and report system-wide metrics to attest meaningful use of EHR to the Centers for Medicare and Medicaid Services.
• Created, altered and implemented T-SQL Stored Procedures for the use of processing consumer data and developing new web delivered tools.
• Collaborate with federal clients (CMS, NIH, ONC) and standards development organizations such asHL7 to develop
• Responsible for UAT project planning like creating testing scenario, test plans, and test scripts.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI x12 Transaction, Code set and Identifier aspects of HIPAA.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Lead SCHIP, CMS request to be able to identify the Medicare eligible candidates.
• Perform responsibilities of conducting research on IT requirements and business requirements in UAT areas.
• Responsible for support and enhancement requests for a SQL 2000 data warehouse and transactional database.
• Performed Regression, UAT, Integration, User Interface, GUI, and Usability Testing and wrote test cases and test scripts, execute test scripts and analyzed outcomes.
• Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for both HL7 ADT interface and the application.
• Generated and maintained SQL Scripts to perform back-end testing on the oracle database.
• Tested and implemented HIPAA 4010 and 5010 and ICD 10, version for all EDI transactions.
• Produced customer functions, complicate SQL commands in Business Object Enterprise XIR2 and Oracle 10g, Crystal Reports XI environments.
• Assist clients in resolving billing issues for Medicare, Medicaid, and private insurance.
• Thorough knowledge of ICD-10 codes and CPT codes for both Mental and Medical Health and worked extensively with Inbound and outbound 834 Transactions processing systems and coordinated in working sessions for testing; communicate risks/issues to ICD-10 project leads.
• Involved in creating sample mappings for the conversion of EDI x12 transactions code sets.
• Coordinated with QA teams in the execution of User Acceptance Testing (UAT)
• Acted as an SME on various subject areas including state reporting, death benefits, Medicare, Bill review and RX eligibility.
• Troubleshooting utilizing CPT4 & ICD-10 codes and Managed HL7 interfaces for PM/EHR software and Lab computers and performed requirements gathering, business process mapping and re-engineering as a part of health exchange readiness efforts for leading public health plan entering state HIX market.
• Lead projects to design a state-customized Financial Management solution for Health Insurance Exchange (HIX).
• Involved in HIPAA/EDI Medical claims analysis, design, implementation and documentation.
• Developed various test cases for testing HIPAA 8371/P/D 834/835 and 276/277.
• Ensured that the Pre-UAT activity is performed accurately and efficiently.
• Developed UAT test process and monitored SIT execution phases.
• Troubleshoot EDI, and XML document errors and troubleshoot translation and mapping errors.
• Developed EDI specifications and applications structures for data feeds and mappings for integration between various systems, including XML and performed back-end testing on the Oracle database by writing SQL queries
• Handle the tasks of helping the organization staff in planning data sets for UAT.
• Created Test Strategy Planning (TSP) and assisted testing team to implement test plans during UAT kickoff.
• Wrote test plans and tested individual transactions for Medicare / Medicaid transactions (835 and 834).

Confidential, Grand Rapids, MI

Sr. Business Analyst

Responsibilities:

• Gather requirements and document the proposed processes to the existing system. Modules included: Claims Processing Files and HIPAA Guidelines adherence across the company.
• Enhanced applications associated with Claim Numbers so that duplicate Claim Numbers could be allowed in the system. Updated the Electronic Claims, Patient Screen and Sales Administration processes.
• Claim Transactions and Billing Transactions - Created flows for adequate matching of Claims. Matched Billing File and EDI Claim File records upon receipt.
• Duplicate Claim Number Project - Enhanced three different applications - EDI Feeds and Patient Screen App to allow duplicate claim numbers to exist in the database.
• Drug Card Project - Worked in a project involving Miami Systems to create Drug Cards.
• Created Test File to be sent to the Drug Card Vendors for approval. Worked on a Paid without prejudice project for various States.
• User Acceptance Testing (UAT) - Performed UAT tests using the MORAE Usability Testing Tool using the Observer and the Manager Mode.
• Testing - Developed Test Scripts using Test Director/Quality Center and coordinated with developers to quickly resolve the defects associated with them.
• Conducted JRP sessions and JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions the performance of the application from various dimensions.
• Helped create the 'Business Glossary' to facilitate efficient understanding of the business process amongst the other teams.

Environment: MS Visio, Word, Excel, PowerPoint, CMMI, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, J2EE technology, Java, Perl.

Confidential, San Jose, CA

EDI Business Analyst

Responsibilities:

• Perform gap analysis between HIPAA 4010 834 and HIPAA 5010 834 Companion Guides
• Perform gap analysis between HIPAA 4010 820 and HIPAA 5010 820 Companion Guides.
• Perform impact analysis of other enrollment processing systems to determine potential scope/impacts.
• Performed thorough analysis of the companion guides from each trading partners both Medicaid and Commercial clients and identified the changes that specific clients need.
• Review with business owners to identify data requirements and business rules based on the changes within the 5010 834 transaction set
• Map the data according to the client requirement.
• Provide dual usage processing capabilities to support both the 4010 and 5010 versions of the 834 transaction set to accommodate those clients who choose to remain on the 4010 version and for those clients who convert to the 5010.
• Monitor state communications to determine if states will be moving from proprietary formats to 5010.
• Prepare Requirement Traceability Matrix, Functional Specification, System Change Documents, Technical Specification Documents, as-is and To-be flows for the entire conversion process.
• Work with the commercial business owners as well as the state representatives in process of gathering the requirements.
• Build a brand new translator for accepting the 834 and 820 X12 5010 files and converting into the flat file layout.
• Mapping the new data in 5010 to the translator to make it 5010 compatible.
• After performing the thorough analysis, design the new translator based on the specific requirement from the commercial and state clients.
• Tested the new translator to verify and validate if the input data is being translated correctly to the correct positions in the Flat file.
• Maintained the dual usage functionality in order to receive the 4010 formatted files for the clients who are not ready to switch to 5010 and 5010 formatted files that are willing to switch to 5010.
• Prepared the common as well as the translator specific test plan for testing the new 5010 process flow.
• Performed System Testing for the X12 formatted data that gets translated to the flat file through translator.
• Set-up the trading partners for receiving either 997 (Functional Acknowledgement) or 999 (Implementation Acknowledgement) and not both.

Environment: Windows, Citrix, MS Office, MS Visio, .Net, SharePoint library, SharePoint Defect Tracking Tool.

Confidential, Mountain View, CA

Business Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Analyzed the "As is" and "To be" system documents to show the current and proposed functionalities of the system using MS VISIO.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Involved in defining and documenting the vision and scope of the warehousing project.
• Worked with ACES and QNXT claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
• Involved in the development of Business and Technical Requirements Document (BTRD) and Business System Design (BSD) document for the project.
• Involved in identifying and studying the ACES and QNXT system data for the attribute mapping purpose
• Conducted interviews with management team.
• Conducted and participated in the JAD session with the SME's and project team members.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
• Designed Use Cases using UML and managed the entire functional requirements life cycle using SDLC.
• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast changing environment to achieve company goals.
• Participated in the walkthroughs and meetings specifically for Claims and Membership modules.
• Coordinate with Development and Business team to develop high level Business and Technical documents.
• Worked with the clients on the verification process for the requirement phase documents.
• Implemented Standardized process throughout the Software Development Life Cycle (SDLC)

Environment: Windows XP, UNIX, QNXT, Rational Requisite Pro, MS Office, MS Visio, UML