SUMMARY:

• Over 8+ years of IT experience as Business Analysis. Dynamic and Assertive team player with strong commitment. Possess excellent verbal and documentation skills complimenting a strong Business analysis background with excellent interpersonal and problem - solving skills.
• In-depth knowledge and experience in full SDLC with RUP, agile and waterfall methodologies.
• A very good team player with excellent communication skills and presentation skills.
• Knowledge on CPDEP documentation and processes.
• Evaluated business plans' viability, capital structure, and compliance with the current e-commerce industry
• Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid.
• Having a very good knowledge on Hedis.
• Expertise in creating the companion guides on various EDI transactions.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider.
• Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277/997 (X12 Standards) processes of Medical Claims Industry from the Provider/Payer side
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensively used SQL scripts/queries for data verification at the backend.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277)
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Experience in Business Requirement and System Specifications Analysis.
• Specialized in creating UML Diagramslike Use Case, Activity and data flow diagrams using Rational Rose and MS-Visio and consistently translate business requirement into IT solutions.
• Expertise in DWH and RDBMS concepts and running SQL queries.

TECHNICAL SKILLS:

Operating System: Microsoft Windows XP/2000/9x, LINUX

Programming Languages: C, C++ and SQL

Business Modeling Tools: MS Visio, Document Analyzer, MS Project

Requirement Management Tool: Rational Requisite Pro

Software Development Guidelines: SDLC, Waterfall, Agile, RUP, UML

Software Application: MS Project, MS Office

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

PROFESSIONAL EXPERIENCE:

Confidential,Philadelphia PA

Business System Analyst

Responsibilities:

• Participated in the requirement gathering discussion to identify all requirements in detail for membership.
• Prepared business requirement document (BRD) to provide details of each business requirement.
• Involved in Reporting GAP Analysis.
• Created mapping document and transformation rules from source to target tables.
• Prepared business requirement document (BRD) for Code Set Development for all subject areas.

MAO-004 Implementation Project:

• Prepared the scope and high level objectives document of MAO-004 project
• Gathered business requirements from the clients to identify the features to be included in MAO-004 Project.
• Prepared business requirement document (BRD) to provide details of each business requirement.
• Created Process flow diagram to give clarity to all stakeholders of the project on the flow of operations/process of the system and timelines of each actors involved in the project
• Prepared Functional Requirement Document (FRD) to help aid the development team understand the requirements in detail

Business Analyst

Responsibilities:

• Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers, and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements
• Conducted Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD), and Systems Requirements Specification (SRS).
• Conducted requirement gathering sessions for MMIS Mainframe Claim processing screens.
• Strong Understanding of State/Commercial Medicaid Claims, Benefit Plans, Claims Payment Cycle, Waiver Programs and Reference
• Strong knowledge of Data Warehousing, and Business Architecture
• Facilitated JAD and JRP sessions with management, development team, users, and other stakeholders to refine functional requirements.
• Used UML for Specifications, Documentation, and Construction of systems.
• Designed and developed Business Rules Document about the Claim Component and HIPPA.
• Validated that the system claim scrubber included editing based on the CEM published edits to ensure a positive 999 and 277CA transaction.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Documented workflows and executed comprehensive testing and training plans to ensure that the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
• Took action in the process flow to prevent rejected claims from falling out.
• Mitigated claim denial increase through a complete analysis to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.
• Actively worked on Data analysis and Reports with respect to Provider Network and Claims Reconciliation.

Business Analyst / Quality Analyst, IT

Responsibilities:

• Created an online presence that allowed prospective customers (Individuals, Brokers, Consultants, Small Groups) to shop, receive insurance quotes, apply and enroll for coverage. It will also allow online membership renewal, premium payments, and real-time member data and policy administration
• Gathered requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
• Created Swim lane diagrams to depict the current and future state.
• AuthoredSystem specification Documents including source- to-target mappings, use case specifications, business process modeling, requirement change request, data dictionary, page layout, error messages, business rules along with the technical staff and developers.
• Applied change requests, versions, and addendums.
• Gathered source metadata definitions from legacy systems. Created and modified DDL on target tables during development when model changes were necessary.
• Applied business rules to conform service center(s) for ETL processing.
• Ensure the business areas identify and implement solutions to regulatory requirements
• Understood and articulated business requirements from user interviews and then translated those requirements into functional and technical specifications.
• Interacted with SME’s (Subject Matter Experts) of different divisions (Information Technology, Policy and Operation) and established a business analysis and design methodology.
• Involved in Joint Application Development (JAD) sessions with the IT Group.
• Worked closely with the UI team to model the screens, which meet user defined requirements, organizational and regulatory standards.
• Assisted to develop the Test Plan, Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge
• Conducted User Acceptance Testing, gathering and documenting User Manuals and Business Rules.
• Wrote SQL queries for data manipulations.

Business Analyst

Responsibilities:

• Interacted closely with the Business users along with the administration and management to gather business requirements and analyze the functionalities to be incorporated into the system.
• Attended demo sessions to understand existing system functionalities.
• Followed the Agile methodology during the entire SDLC.
• Formulated Data Mapping Guide for the technical team.
• Coordinated with system architects and developers to convert business requirements into system requirements.
• Experience with Web Development E commerce projects.
• Facilitated JAD and JRP sessions with management, development team, users, and other stakeholders to filter functional requirements
• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Conducted meetings to document Change Requests for new requirements.
• Analyzed business requirements and segregated them into Use Cases. Created Use case diagrams and documented Use case specifications.
• Maintained various versions of the documents generated during the project using Rational Clear Case.
• Was responsible for creating and updating project schedule and managing resources and timeline using MS Project.
• Worked with the ETL development team to migrate the data from the old data mart to the new IDW (Insurance Data Warehouse) and to validate the data integrity.
• Prepared the project status reports and represented the BA team in the PMO meetings.
• Participated in UAT along with Business SMEs.

Business Analyst

Responsibilities:

• Analyzed client’s systems and business processes.
• Addressed all aspects of credit card business
• Established a Business Analysis methodology around the Rational Unified Process.
• Researched the various steps in the lifecycle and then constructed the system in a way that the high risk customers would be easily identified and monitored.
• Streamlined clerical work processes and mapped then into the new system.
• Developed project plans and managed project scope.
• Assisted in building a Business Analysis Process Model using Rational Rose and Visio.
• Performed extensive Requirement analysis and developed use cases and workflows.
• Developed requirement reports for day to day servicing needs using Rational SODA.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams.
• Played a key role in the planning, User Accepted Testing, and Implementation of system enhancements and conversions