SUMMARY:

• I have 7 years of diverse experience as a Business System and EDI Analyst in developing and implementing innovative business processes .
• In - d epth kno wl edg e an d exp erience in fu ll S D L C w i th R UP, ag ile and w a te rfal l m eth o d o l o g ies.
• Expertis e in cr eat in g t h e co m p an io n gu id es o n v ari o u s EDI tr an sac ti on s .
• Goo d k no wledg e in HI PAA5 0 1 0 i m p le m en tati o n includ in g GA P anal y si s.
• P ro f o un d und erst and in g o f in sur an ce p o licies like HM O, PPO, EPO an d POS wit h p ro v en e xperienc e in HI PPA 4 0 1 0 ED I trans acti o n c o des such as 2 7 0 / 27 1 ( inqu ire / resp o n se h ealthcare b en efits ), 2 7 6 / 2 7 7 ( Clai m statu s), 8 3 4 (Ben efit enroll m ent ), 8 3 5 ( P aym ent/ re m ittanc e ad v ic e), 8 37 (H ealth car e clai m ).
• Kno wledg e in i m p act an alysis o n the ke y app lica tio n s y ste m s (clai m s pr o ces sing, reporting, pay m ents )an d bu sin ess p ro c es s o f he alth in sur an ce c om p an ie s.
• Clear und erst and in go fI C D -9 -CMan dI C D-1 0 -CM/ P CS.
• Goo d kn o wledg e o f Fa c e ts supp o r ts s y st em s whic h we re u sed to enab le inb o und /o u tb o un d H IPAA ED I Tran sacti o n in supp o rt o f H I PA A 83 4, 83 5, 83 7, 2 7 0/ 2 7 1tran sa ctio n s
• M edi cal Cl aims e xp er ien ce in P ro ces s D o cu m enta tio n, An alysis and I m p le m entati o n in 8 3 5 / 8 3 7 /8 3 4/ 2 7 0 / 2 7 1/ 2 7 7 / 9 9 7 (X 1 2Stand ard s) pr o c esse s o f M edic al Clai m s Indu stry fro m t h e P ro v id er/ P a y er sid e.
• Experience in Healthcare/ClaimsadjudicationwithknowledgeofindustrycompliancestandardslikeHIPAAand
• EDI X12 transactions (834,837,835,270/271and276/277).
• Well versed with ANSI X12, EDIFACT EDI and HL7 standards.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing and tracking requirements.
• Knowledge in creating prototypes and mock-ups f o r u ser in te rfa ce d esign s.
• Kno wl edg einClai m s,Subs crib er/ M e m b er,P lan/ P r o du ct,Clai m s, P r ov id er,Com m issi o n san dBil lin gMo dul eso fFa cet s
• Sp ecializ ed in cre atin g UM L Di ag ra m s like Use Cas e, Activit y an d d at a fl o w d iag ram s u sin g Rati o n al R o se an d M S-Vi sio an d co n sis te n tl y t ran slate bu sin ess re qu irem ent in t o IT s o lu ti o n s.
• Kno wl edg e in R D B M S c o nc epts an d runn in g SQL qu eri es.

TECHNICAL SKILLS:

Technologies/Tools: MS Project, Visio, Excel, Word, Outlook, Power Point, iRisestudio Requirements Management Rational Requisite Pro Rational Rose, MS Visio

Healthcare: EDI X12, 834, 837, 276/277, 278, 820, 835, HIPPAA 4010, 5010

Defect Tracking Tools: HP Quality Center, Rational Clear Quest

Languages/Standards: SQL, XML, HTTP, Java, HIPPA 4010/5010, ICD9/10, ANSIX12

Methodologies: Rational Unified Process (RUP), Agile, Waterfall

PROFESSIONAL EXPERIENCE:

Confidential, Raleigh, NC

Sr. EDI An a l y s t / Business Analyst

Resp on s i bi li t i e s:

• Responsible for participating in the design sessions, reporting on project progress and identifying potential risks and issues.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems.
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Defined and documented the vision and scope of the project.
• Gathered requirements, developed Process Model and detailed Business Policies.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Involved in writing and implementation of the test plan, and various test cases for UAT.
• Analyzed EDI transactions in XML and X12 responses.
• 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. Assisted in developing Project Proposal, Business Case.
• Analysis of existing data requirements using SQL to document functional requirements from high level User Stories.
• Extensively involved in creating and entering dummy data to test the functionality of various modules of EDW and how the modules integrated with the EDW database and the Facets database in the backend.
• Conducted Data analysis using SQL on the backend databases for producing mapping documentation and transformation rules for developers
• Configure Providers (Individual, Group and IPAs) per Provider Change Management application (PCMA) load information and utilize Contracts module to identify appropriate contracts and networks for non/credentialed providers using legacy fee tables crosswalks, signed contracts, NPI Registry, EDI 835 & 837 Claim image (1500 & UB04).
• Produced for transaction sets EDI 820, 834, 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy as per X12.
• Design and maintain all EDI maps to ensure compliance to all business requirements and analyze all EDI implementations and recommend improvements to processes and coordinate with trading partners to resolve all issues effectively.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Worked on Health care Eligibility and Benefit, Claim Status transactions 270/271, 276/277, 835, 837 based on the HIPAA compliant ANSI X12 version 4010/5010
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 834, 820, 835, 837, and HIPAA EDI Transactions across enterprise.
• Prepared the Business Workflow using MS-Visio with input, output, Pre and Post conditions.
• Enhanced test cases and scripts by adding the required functionality as per the new business requirements.
• Responsible for analysis of discrepancies in the eligibility reconciliation process for multiple stakeholders and continuous process improvement of the reconciliation process.
• Performed numerous data extraction requests involving SQL scripts
• Direct knowledge and experience with the following elements ANSI X12 5010, EDIFACT, Multiple VAN’s Gentran /GIS.
• Responsible for accomplishing business objectives by identifying and solving customer information and processingproblems.
• Created XML configurations to accurately parse EDI, EDIFACT, CSV, and Excel data files into the Info Now Oracle database
• Assisted end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS (Data Base Management System).

EDI An a l y st

Resp on s i bi li t i e s:

• Gathered business requirements through discussion with stakeholders and SME’s.
• Performed Gap Analysis for HIPAA 5010.
• Involved in activities to make sure proper documentation and standards are being followed.
• Wrote Business Requirement Document after collecting requirements through conducting interviews, JAD Sessions and brain storming sessions.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions related to providers, payers, subscribersandother related entities.
• Developed use case Designed process flow diagrams using MS-Visio and also Business Context Diagrams.
• Created Data Mapping to document to migrate data from the existing system to the new system.
• Strong Documentation and Report Generation skill and experience by Use case approach.
• Participated in software upgrades for claims work flow and EDI transactions (835,278) upgraded from Version 4010 to 5010.
• Worked extensively on EDI transactions 837 and 835 Involved in writing test cases for different LOB’s (ITS, FEP And Regular) for SIT, Parallel and UAT.
• Worked on 270,271 Eligibility request and Eligibility response and on 276,277 Claim status request and response.
• Validated that the 270/271 generated is in accordance with the 5010 implementation guide.
• Mapped EDI 834 transaction to BCBS LA enrollment/eligibility system to comply with State of Los Angeles Health Care Reform Project. Ensured accurate enrollment data for health plan products across multiple systems.
• Assisted developers in trouble shooting and resolving EDI issues by collaborating with internal and external business partners to define business processes and information requirements by building on intermodal industry best practices and ANSI X12EDI standards.
• Used FACETS 4.71: Subscriber/Member, Medical Plan to validate the Eligibility benefits received in the 271 response.
• Performed parallel testing for the 83xtransactions to ensure comparable results between 4010 and 5010 transaction processing with the help of XC file comparisons, Keyword file comparisons and other significant file structures with end-to-end testing cycle Analyzed and provided compare results for production XC’s (External Claims) and test XC’s for all LOB’s after every build to validate if the defect were fixed.
• Used SQL Queries to verify the data from the Sybase database.
• Used Edifecs Transaction Management tool to verify that the batch and real-time files are generated correctly.
• Used the iLink Blue Provider Suite to test that the 270/271 eligibility requests and responses and the 276/277
• Claim status Request and Response are generated according to the 5010 format. Validated the same.
• Creating and consolidating SIT Test Cases and UAT test Cases using MS Excel or Quality Center.
• Was involved in working with the offshore testing team to co-ordinate Regression Testing.
• Preparing sample Test Data and executing Test cases using Quality center.
• Provide support to end users while execution of UAT with proper test scenarios & test data.
• Monitored RTM to close the defects/cases as and when developers resolved the defects
• Communicated with developers and Business Analysts through all phases of testing to prioritize defect resolution.
• Reporting the Test Execution status to the project manager on daily basis.
• Good understanding of 5010 conversion initiative
• Actively involved in weekly walkthrough meetings and Daily Defect calls to verify the status of the testing efforts meeting the deadlines & mid-term targets

E n v i r on me n t: M S Vi si o, Ed ifecs Tran sa ctio n M an ag em ent, iLin k Blu e P ro v id er Su ite, M i cro s o ft SQL S erve r, Qua lity C enter, IB M D B2, Syba se, M S W o rd and M S Exc el

Business Analyst/EDI Analyst

Responsibilities:

• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus for BRD and FRD and business docs.
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
• Acted as a liaison and conducted meetings, JAD sessions and presentations with the teams
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) and 820) standards
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Eligibility.
• Prepared requirements documents for conversion of 834 4010 to HIPAA compliant 5010.
• Worked in ANSI x12 837-835 EDI Transaction.
• Worked on HIPAA Standard/Gstandard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 to identify key data set elements for designated record set. Interacted with Eligibility, Payments and Enrollment hence analyzing and documenting related business processes.
• Initiated with a comparison report of migration of 4010 to 5010. 270 Eligibility, Coverage or Benefit Inquiry (V4010X092A1) vs. 270 Eligibility, Coverage or Benefit Inquiry (V5010X279), 278 Prior Authorizations.
• Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277, 278 837P, 837I, 837D, 835 remittances)
• Used General equivalence Mappings (GEM) to convert ICD9 to ICD10.
• Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with Use Cases from the analysis.
• Worked with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD9 to ICD10 and backward mapping from ICD10 to ICD9 using General equivalence Mappings (GEM).
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Documented the dimensional models of ETL system.
• Worked on Audit/Edits reconciliation for claims codes to correct any configuration and documentation inaccuracies and updated Audit, Edit and Claim Check Manuals as required.
• Designed and created SQL Databases tables, indexes, and views, User Defined Functions, Stored Procedures and Triggers based on user requirements.
• Assisted in Regression Test, System Test, and UAT.

Environment: Microsoft SharePoint, MS Visio, MS Office, HP Quality Center 10.0, Toad for Oracle, Team Track, AGILE methodology, COGNOS

B u s i nes s Sy stem A nal y st

Resp on s i bi li t i e s:

• Analyzed Business Requirements and segregated them in to high level and low level Use Cases, Activity and Sequence using MS Visio according to UML Methodology.
• Prepared Crosswalk documents for ICD 9 and ICD 10 Procedure and Diagnosis codes.
• Conducted JAD sessions with project's stakeholders such as users, QAs and project management team to identify and resolve issues.
• Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
• Conducted Claims and HIPAA Compliance Training to run the test cases. Also worked with NPI
• Experienced in X12 transactions 835/837/834/820/271 of medical claims/underwriting for support and point of reference for the vendor in business issues.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML.
• Manage RTM (Requirement Traceability Matrix) to track the project flow.
• Prepared BRD and Derived Functional Requirement Specifications (FRS) based on User Requirement specifications and delivered to the project team. Understand and articulate business requirements from user interviews and then convert requirements in to technical specifications
• Worked extensively on 837I, 837P, 837D, 835, NCPDP and NCPDP response files.
• Facilitated User Acceptance Testing (UAT) with stakeholders and the business users.
• Frequently updated the requirements and defect status as per the current status of the Testing project in the Clear Quest.
• Project Management and Controlling to ensure on time delivery using MS Project.
• Used guidelines and artifacts of RUP to strategize the implementation of the Rational Unified Process effort in different iterations and phases of the Software Development Life Cycle (SDLC).
• Worked on Health care Eligibility and Benefit, Claim Status transactions 270/271, 276/277, 835, 837 based on the HIPAA compliant ANSI X12 version 4010/5010
• Documented the Use Cases and prepared the Use Case and Activity Views using MS Visio and Rational Rose for a clear understanding of the requirements by the development team.
• Developed timelines for project delivery, and managed projects and resources to successful completion.
• Involved in writing Data Mapping Documents for the system and involved in documenting the ETL process and writing SQL Queries for the retrieval of the data
• Performed Data Analysis on the extracted data, data cleansing and scrubbing.
• Validated the database by applying business rules using SQL queries

Environment: Rational Rose, HP Quality Center, BizTalk, Putty for UNIX, SQL Developer, Power Point Comparison Tools (Visual Studio), \ BI, ETL, Crystal Reports, Microsoft Project, Quality Assurance, Testing Life Cycle, Promotion Processes.

B u s i nes s An a l y st

Responsibilities:

• Participated in creating Facets data model.
• Worked on the EDI 834-file load to Facets through MMS (Membership Maintenance Sub-system)
• Performed requirement gathering by interacting with business users and documented the requirements
• Worked with business users and solution engineers to solve the capture defects in the MMS system and to effectively solve them.
• Performed Data Mapping to map the EDI 834 data to XML.
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Conducted JAD Sessions, Peer Review sessions with the SMEs, Solution Engineers, developers, Business users.
• Analyzed the scope of the project to review it with the customers for different review sessions of the application.
• Experienced in X12 transactions 835/837/834/820/271 of medical claims/underwriting for support and point of reference for the vendor in business issues.
• Intensively involved in project testing efforts by helping testers perform System Integration Testing, Regression Testing and by helping UAT team in User Acceptance Testing (UAT)
• Used to execute test cases for several transactions such as 837, 835, 820, 834, 277, 278, 270/271
• Created SQL queries to read data from databases.
• Executed Test cases manually by composing 270, 276,837 EDI files and dropped inbound and check response 271,277,835 using interleaves and outbound.
• Performed Data Mapping to map the EDI 834 data to XML.
• Worked on EDI 834, 835,837 as per HIPPA guidelines.
• Requirements Gathering & Analysis always ensured HIPAA Compliance Auditing
• Worked with the Testing team to test the system extensively and log defects.
• Defined the maps from the existing BizTalk solution and validated it with the client for any changes.
• Performed data mapping and tracing data from system to system in order to solve a given business or system problem.

Environment: Ms Office Tools, MS Project, MS-PowerPoint, SQL Server, XML, Mercury Quality Center, Agile framework.