SUMMARY:

• Senior Business Analyst with 7+ years of experience in all disciplines of Business Analysis including process modeling, process re - engineering, requirement elicitation/documentation/management, test planning/scripting/executions, and systems specifications
• Extensive knowledge working through the Software Development Life Cycle (SDLC) including Enterprise Analysis, Requirements Planning and Management, Requirements Elicitation, Requirements Analysis and Communication, Solution Assessment and Validation of Projects. Excellent analytical and problem solving skills in designing, developing and implementing innovative business processes using new approaches and technology.
• Worked on the HIX Program
• Excellent knowledge of health care industry and claims management.
• Experience with the working of Medicare (Part A, B, C and D) and Medicaid Health Insurance Policies, Personal Injury Protection (PIP) insurance, billing experience with life and disability in health plans with thorough understanding of CPTcoding, UCR, FS, HCFA-1500 and CMS-1500 claim forms and reimbursement forms.
• Extensive knowledge of Medical Management Information Systems (MMIS), and National Provider Identification (NPI)
• Sound understanding of comprehensive health reform, the Patient Protection and Affordable Care Act (ACA) and medical claim policies and requirements including benefits, membership, enrollment and implementation.
• Experienced in HIPAA compliance, Electronic Data Interchange (EDI) and implementation of HIPAA code sets, ICD-9, ICD-10.
• Extensive knowledge in insurance products like HMO, EPO, PPO, POS and managed care.
• Expertise in ICD-9 to ICD-10 Conversion & creating a crosswalk between ICD-9 to ICD-10
• Thorough understanding and hands-on working experience with standards of EDI/X12- 270/271 & 276/277, 834, 835, 837
• Experience with QNXT 3.4, QNXT 4.6, Facets 4.71, Inbound & Outbound interfaces, EDI configuration, and data mapping using ANSI X12 4010 and 5010.
• 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.
• Extensive knowledge of Object Oriented Analysis and Design (OOAD) using Unified Modeling Language (UML), Rational Unified Process (RUP), Waterfall, CMMI, Six Sigma (DMAIC).
• Hands on experience with UML modeling, Use Case Documents, Use Case Diagrams, class diagrams, interaction diagrams, activity diagrams, state chart diagrams and documentation of each and every method and attribute
• Prepared multiple Statement Of Works (SOW) as formal document that captured and defined the work activities, deliverables, and timeline a vendor must execute in performance of specified work for a client
• Expert in Tracking, Managing and verification the requirements using Requirements Verification Traceability Matrix (RTM) that links and controls numerous artifacts produced by several teams across the deliverables of the project.
• Elicit, Analyze, Create and Review of Business Requirement Documents (BRDs), Functional Specification Documents (FSDs), Use Case Documents, and Business Rules Spreadsheets (BRS), Standard Operating Procedures (SOPs)
• Good experience with Rational Rose, Rational Requite Pro, Rational Clear Quest, Rational Clear Case, MS Project, MS Visio, Rational DOORS, Crystal Reports.
• Working knowledge and experience with SQL/PL SQL, HTML, and MS Access
• Expertise in understanding business needs and defining creative and useful software solutions.
• Skilled at working as a liaison between the business owner and IT personnel for communication requirements between the two communities.

TECHNICAL SKILLS:

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

Project Management Tools: MS Project, MS Office Suite (Word, Excel, PowerPoint, Access)

Databases: SQL Server, MS-Access

Business Modeling Tools: SmartDraw, MS Visio, UML 2.0, SnagIt

Operating Systems: Windows 10/8/7/NT/XP, Linux

PROFESSIONAL EXPERIENCE:

Confidential

Senior Business Analyst

Responsibilities:

• Performed as a high-visibility business relationship management liaison, working with internal and external business owners / customers (e.g. including website stakeholders).
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Performed System testing of the Claims processing systems (Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment, et al).
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Conducted interview sessions with primary care staff and JRP sessions with health informaticians (physicians), stakeholders and subject matter experts to identify the needs of the integrated system.
• Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using Confidential Visio.
• Conduct complex documentation and user needs analysis. Interface with team and staff to develop HL7 integration.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Designed the primary templates of the flow of the new system with HIPAA rules using MS-Office and Visio.
• Checked and converted all the legacy system into the standards of HIPPA which included National standards for EDI, Unique health identifiers, Security standards, privacy and confidentiality.
• Developed documents to design the data to be accepted in HIPAA Compliant 837 (4010A1), National Standard Format (NSF) other proprietary formats and to be converted into the required format by the provider/clearing houses/Insurance agencies.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
• Enforced change management process and captured all changes as new revisions of system documentation.
• Conducted GAP analysis in comparison to the proposed system to enhance the functionality of the system, which had to fulfill the 3 formats.
• Wrote test cases with all required information for further analysis.
• Created reports using MS-Word such as Error Summary Report, Submissions Report, and Payers Responses Report. These were used for further claim version reports for the providers.

Environment: Oracle, MS-Office, IBM DB2, MS-Visio, MS-Suite, IBM curam and SharePoint.

Senior Business Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements, qos requirements, and documentation.
• Understood the As Is system and developed the To Be system concept after client interviewing.
• Successfully conducted workshops and JAD sessions, which helped synchronize the different stakeholders, SMEs on their objectives and helped the developers to have a clear-cut picture of the project.
• Utilized Agile Methodology using Scrum framework. Actively participated as the Product Owner in creating the user stories, prioritizing the user stories, setting the acceptance criteria and most importantly maintaining the Product Backlog.
• Created Flow Charts and Process Flow diagrams, Use Case Diagrams, Class Diagrams, Activity Diagrams / State Chart Diagrams using BPMN, Confidential Visio and Rational Rose according to UML methodology thus defining the Data Process Models.
• Successfully completed the CMS MIPS (Medicaid Incentive Program System) processing and Attestation Validation in the CMS portal.
• Worked on claim processing receipt and verification of the claim forms (837) and claims attachments (275), claim Enquiry and Response (276/ 277).
• Oversee the EDI process, working directly with trading partners to enhance the secure and HIPAA Compliant electronic flow of information.
• Responsible for Claims Editing due to data entry error, enrollment adjustments, configuration errors etc.
• Effectively used Facets version 4.7 for integrated claims management, claims enrollment and adjudication.
• Analyzed Facets Benefit Plans and Contracts module as well as related modules in order to identify data requirements for script design developers.
• Worked in Facets Reconfiguration of member/subscriber, Data Element Definition.
• Analyzed Business Requirements and segregated them into high level and low-level Use Cases.
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed, BI reporting and also monitored the revisions.
• Designed and maintained the Requirements Traceability Matrix.
• Retrieved data from database for Data Validation and Data Integrity tests using SQL queries.
• Assisted QA team in creating Test Cases and performed User Acceptance Testing, functional testing logged defects using the Defect Tracking report.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Conducted presentations of the QA test results to the stakeholders and users and documented modifications and requirements.

Environment: Windows XP, MS Office Suite, MS Visio, MS Project, SQL, Facets, Rally.

Business Analyst

Responsibilities:

• Identified and validated high potential business opportunities for stakeholders.
• Gathered business Requirements, analyze data/workflows. Defined the scope and progressed from problem Statement to well-documented Designs
• Utilized Rational Req Pro as a user to analyze the business requirements
• Worked on MS CRM Dynamics for handling the customer claim inquiries, Validation and case creation.
• Facilitated with JAD sessions with the management groups, vendors, users and the IT Group for open and pending issues to develop specifications.
• Conducted Functional Walkthroughs as well as User Acceptance Testing (UAT) sessions.
• Developed Use Case diagrams with MS Visio and also created Business Flow Diagrams, Activity/State diagrams, and Sequence diagrams, which enabled developers and other stakeholders to understand the business process
• Created business process workflow diagrams (Activity diagrams) in Rational Rose.
• Worked through Software Development Life Cycle (SDLC) from Requirements, Analysis, Design, and Implementation through Testing.
• Worked as an Interface between the users and the different teams involved in the application development for the better understanding of the business and IT processes
• Conducted iterations, communicated results, and milestone achievements to the stakeholders while keeping the developers closely updated on all documented refinements.
• Created and maintained a project schedule using MS Project showing all target dates for deliverables.
• Created and maintained complete development plans that included functional specifications, requirements engineering, Use Case modeling, risk assessment and mitigation, internal and external workflow.
• Extensively used ETL to Extract, Transform and load data.
• Developed Scripts for Regression Testing and System Testing.

Environment: Windows, UNIX, C++, HTML, XML, Rational Rose, Rational Requisite Pro, SQL, MS-Project.

Business System Analyst

Responsibilities:

• Developed the prototype for PDA application “Rehab without walls” for interfacing with billing and invoice application
• Worked under the Governmental compliances like HL7, EDI, PHI, and HIPAA standard.
• Worked on ‘FACETS Healthcare Solution’ to make the organization efficient in responding quickly and effectively to the change around the healthcare market.
• Developed Templates to gather the requirements for applications to be added in SATS
• Worked on Medicare, Medicaid, including compliances like HL7, HIPAA, EDI Transactions (270/271 Benefit Inquiry- Eligibility, 276/277 Status Request- 834 enrollment, 835 Payment/Advice and more), PHI, ICD 9 and many other compliances.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, information needs and insured that critical requirements are not missed
• Involved in planning, execution, coordination of entire testing (QA) life cycle
• Developed strategies for Test Planning, Test Case Designing, Test Scheduling, Test Estimation, Test Execution and Defect Tracking
• Assisted the QA team in SIT and Business in UAT

Environment: Medicare Software, ezclaim, Oracle, FACETS, Medicaid, HIPAA-compliant patient information management and billing system and Confidential Office package, Metadata, Data Warehouse, SQL.

Business Analyst

Responsibilities:

• Acted as an interface with different stakeholders of the project.
• Defined Business Rules by interacting with stakeholders and users through Surveys & Brainstorming.
• Developed a vision plan that defined the primary goals and objectives of the project.
• Conducted Joint Application Development (JAD) sessions.
• Performed Gap Analysis, conducted walkthroughs and acted as a liaison between the business users, stakeholders and the team to perform requirements, quality and risk analysis.
• Involved extensively in the inception phase for understanding the Scope of the Project, feasibility of the implementation and define the risk factors involved in the project.
• Gathered business requirements through sessions and analysis by interviewing users and Subject Matter Experts
• Analyzed business/system requirements using requirement arbitrage and assigned appropriate priorities.
• Documented AS-IS and TO-BE analysis, and conducted process evaluations and write recommendations based on the analysis.
• Applied Unified Modeling Language (UML) notations and methodology in developing models that accurately represent the business process and workflows to effectively communicate them to the stakeholders.
• Got system approvals by conducting UAT sessions.

Environment: Unified Modeling Language (UML), Confidential Word, Confidential Excel, Confidential PowerPoint, MS Project, Confidential Visio, SQL, SDLC, SCRUM methodology.