SUMMARY:

• Seven years of professional experience as a Business Analyst in the Health Care domain and Extensive experience in analyzing and requirements gathering and writing system functional specifications including use cases.
• Highly motivated team player with excellent communication, presentation and interpersonal skills, always willing to work in challenging and cross - platform environment.
• Strong knowledge on the Systems Development Life Cycle (SDLC), Rational Unified Process Methodology (RUP), RAD, SWOT, and CRM.
• Strong skills in creating UML Diagrams and Data Models including Use Case Diagrams, Activity Diagrams, Deployment Diagrams, Data Flow Diagrams (DFD) and Entity-Relationship diagrams using Rational Rose and MS Visio.
• Extensive exposure to unified modeling language (UML) tools such as MS Visio, Rational Rose and Requirement Management tools such as Rational RequisitePro.
• Significant practical experience using the Rational Unified Process (RUP) methodology-workflow and Implementation.
• Extensive work with various Rational tools like RequisitePro- Requirement gathering/maintenance, Use Case document maintenance, Clear Case- version control and Clear Quest/Test Director for bug tracking, Rational Rose for Use case diagrams, Sequence diagrams and activity diagrams.
• Experience in preparing Systems Proposal Reports and performing GAP analysis.
• Extensive working knowledge of QNXT on projects independently and also managed a QNXT testing effort.
• Experience with Trilete Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Strong knowledge of Business Intelligence, Data Warehousing, Business Process Re-engineering and Business Architecture.
• Experience with TriZetto Facets and TriZetto HIPAA Gateway - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Organized Joint Application developments (JAD), Joint Application Requirements sessions (JAR), Interviews and Requirement Elicitation sessions.
• Experience with Claims, enrolment, eligibility verification for members and providers, benefits setup, and backend payment cycle.
• Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.

TECHNICAL SKILLS:

Process/Modeling Tool: Software Development Life Cycle (SDLC), MS Visio, Rational Rose, Rational Requisite Pro, Rational Clear Quest, VSS.

Methodology: UML, RUP, Agile, Business Modeling

Databases: MS Access, SQL Server, OracleLanguages SQL, Java, XML and HTML, Mainframe, .NET

Operating Systems: MS-DOS, WINDOWS, UNIX, LUIX.

Office Tools: MS Project, MS Office, Word, Excel, PowerPoint, Access

Testing tools: QTP, Test director

PROFESSIONAL EXPERIENCE:

Confidential, KY

Business Analyst

Responsibilities:

• Designed the architecture of (LMS) Lead Management System and the database structure for seamless client communications and rewards management using UML methodologies.
• Analyzed clients systems and business processes.
• Monitor end to end process of Kentucky Medicaid Encounters and ensure their timely submission to the state
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Experience in participating in walkthroughs and reviews with stakeholders and subject matter experts; facilitating "problem solving sessions" to drive out issues and root cause with solutions obtained by consensus
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation & Verification process. Worked with Claims, enrolment, eligibility verification for members and providers, benefits setup, and backend payment cycle in facets.
• Designated as the key resource for State Medicaid encounters.
• Partnered with clients and developers to communicate challenges, trouble-shoot technical issues and perform root cause analysis
• Supported the contact center platform and peripheral systems on a day-to-day basis to ensure fast response and timely fix of issues, facilitate root cause analysis and initiate and follow through issue escalation when appropriate.
• Responsible for QNXT Group Member Premium configuration set up and maintenance, Provider Reimbursement configuration set up, Maintenance and Medical Management configuration.
• Established a Business Analysis methodology around the Rational Unified Process.
• Interaction with underwriters to understand multiple data points. Prepared data flow diagrams using MS Visio for better clarity and to ensure documented process
• Experience in configuration of claims adjudication systems, i.e., Amisys, Facets, QNXT.
• Created reports using Microsoft SQL Server Reporting Services and QNXT tables
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT that would take several man hours to complete via the front end software.
• Managing personnel allocation and SDLC process for systems projects enhancements
• Worked extensively with MS Excel and MS access
• Defining test cases, creating test scripts, analyzing bugs, interacting with QA / dev teams in fixing errors, SIT and (UAT)
• Tested and delivered Inbound/Outbound Facets interfaces.
• Assisted in building a Business Analysis Process Model using Rational Rose and Visio.
• Skilled in creating Business Requirements Document (BRD) which contain the complete detail of what and how the changes are implemented in the Medicaid Encounters system.
• In-depth knowledge of Claims/Encounters lifecycle -Extract from claims processing (QNXT) to encounter systems (EDM, EMS), data transformation and accuracy, export to files for submission to state.
• Interacted with stakeholders to create test cases, UAT, root cause analysis and corrective action plans
• Responsible for reading, deciphering, and translating provider contracts to the QNXT database to ensure proper reimbursement for Client providers
• Performed extensive Requirement analysis and developed use cases and workflows.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Performed usability analysis and testing including user interface design throughout the development life cycle, provided Client meetings, Artifacts and end-user training on application usage and General IT knowledge.
• Gather final requirement and draft the BRD and Business Data Flow Diagrams
• Conducted JAD sessions for communicating with Stakeholders and Project directors.
• Developed business requirement specification documents as well as high-level project plan.
• Responsible for all risk assessment and management activities including business continuity, disaster recovery planning and physical and information security.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, levelled technique for building Business Process Models.

Environment: Mainframes, COBOL, QNXT TOAD, JCL, Db2, SQL Server, Oracle, VB.Net, Rose, ETL, Perl, MS Word, MS Excel, MS Visio, Load Runner, Win Runner

Confidential, Round Lake, IL

Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Prepare and maintain project budget and forecast data, modify and enhance macros and code in MS Excel for corporate forecasting tool, assess business processes for spending effectiveness for the state health plan
• Involved in making Marketing Plan & Strategies for Mobile Web application and also building B2B relationship with Sales budgeting & Forecasting.
• Involved in Processing QNXT 837 Healthcare Claims (Institutional and Professional) in PORTAL with valid TPI.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Responsible for determining the root cause actions that caused member to file a complaint with Medicare against Confidential . Provided feedback to improve quality and efficiency based on the root cause data.
• Create a root cause metric to identify areas of opportunities within pricing
• Worked with internal and external users to define requirements and coordinated user management and developer expectations.
• Involved in testing QNXT Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.
• As a consultant, used UML and OO discovery methods to perform discovery for new enterprise wide installation of Trizetto FACETS (both core and extension requirements) using Rational Rose
• Executed project management functions including project planning(WBS), budgeting, business requirements, technical design, systems specifications, and project deliverables
• Knowledge and experience with Medicaid Encounters submissions including 837, and 277 files.
• Checked Business Readiness and determined activities of flow.
• Analyzed the QNXT (claims engine) data and discussed with the Business team regarding the Requirements.
• Trizetto QNXT for member demographic information, and other related information.
• Implemented process improvement initiatives throughout SDLC by root cause analysis to identify and eliminate issues leading to time and cost savings by developing metrics and ensuring quality deliverables.
• Wrote Procedure Manuals and responsible for continuity preparedness.
• Managed various tests, stored test information, reviewed and analyzed test results.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirement.
• Provide root cause analysis for all pricing tickets.
• Analyzed and tested various Common Eligibility Outbound Interface Process and other Inbound/Outbound Facets interfaces.
• Proficient in Unit Test Plans (UTP), Integrated Test Plans (ITP) Extensive experience in User Acceptance Testing (UAT).
• Experienced in analyzing large and complex data sets to generate insights, identification of root causes and solutions to address business problems
• Coordinated various kinds of User Acceptance Testing (UAT) including regression testing, system testing, integration testing, functional testing, alpha & beta testing.
• Loading the data into Oracle Database to verify data integration by using SQL plus.
• Performed requirements modeling and develop analysis diagrams, activity diagrams, sequence diagrams, state diagrams, data models, and use-case realizations using RUP tools in Agile.
• Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
• Used Test director to link the description and documentation of project requirements.
• Provided detailed traceability views that display relationships and show requirements by using Test director.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Configured the Data mapping between Oracle and SQL Server.
• Coordinated and developed QA activities with team members to support the Scrum methodology.
• Maintained proper communication with the developers ensuring that the modifications and requirements were address and also monitor these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.
• Performed (UAT) once QA Manager approved the application and it was migrated to the User Acceptance Testing Environment.

Environment: PL/SQL, AS/400, Windows, Mercury Quality center, QNXT, Agile Methodology, MS Office, .Net, Rational Clear Quest, Rational Clear Case, Microsoft office, Word, Excel, Power point

Confidential, Hershey, PA

Business System Analyst

Responsibilities:

• Responsible for interacting with client for requirements gathering, analyzing requirements, and creating detailed specifications
• Analyzed plan requirements and then contributed further defining the plan requirements with their Project Manager. Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements
• Maintained and enhanced NextGen Electronic Medical Records (EMR), Electronic Practice Management (EPM), and Imaging Control System (ICS) software
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA (4010A1)/ EDI formats and accredited standards like ANSI.
• Working knowledge of implementing software development projects using methodologies such as Waterfall, Rational Unified Process, and Agile/Scrum.
• Proposed agile methodology to capture the Business Requirements.
• Conduct analysis to determine root cause of identified problem areas and provide recommendations for process change for Moody's Financial Metrics applications.
• Managed between clients, onshore and offshore team to get the production issues fixed by guiding the team to identify the root cause and leading through fixing of the issues.
• Working knowledge in ICD 9/ANSI Health codes/HL7/ADT in the claims environment for inpatients and outpatients; reviewed the implementation of the changes made in the systems as per the formats and compliance for EDI usage.
• Identified root cause of a given business issue and resolved it at its starting point
• Performed root cause analysis on model errors and alerts and identified steps for resolution.
• Designed High level design, for New process, integrating with legacy and Facets
• Researched EDI claims and claims adjustments data to determine root causes of data errors
• Defined Functional Test Cases, documented, Executed test script in Facets system
• Created and effectively executed comprehensive Test Plans and Test Cases for Data Integration's architectural and functional development including high end logic analysis and ongoing enhancements and fixes
• Designed, test, and customized EMR templates, documents and crystal reports
• Created documents using Documents Builder for templates
• Installed and setup Interlink Electronics e-pad for electronic signature on documents
• Edit/Add new information using File Maintenance
• Defined Functional Test Cases, documented, Executed test script in Facets system
• Developed and executed SQL queries on claim records to validate reporting data
• Created and executed SQL Queries
• Designed and documented Test Cases according to the application requirements using Quality Center
• Coordinated and attended meetings to review these specifications with the Quality Assurance Manager, Business Systems Analysts, RUP Engineers, Project Manager & others on the team
• Worked closely with the development team to communicate client requirements
• Reviewed Test Cases for EDI transactions and executed them in Quality Center testing environment
• Participated in the bug review meetings, Updated requirement document as per business user feedback and change in functionality of the application.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Designed and implemented SQL queries for QA testing
• Performed Unit Testing and User Acceptance testing and documented detailed results.
• Assisted client in developing content and training materials; recommended enhancements and identified new business requirements ensuring appropriate documentation
• Trained providers, administrators, and staff on implementation and use of NextGen’ s EHR and EPM
• Worked effectively with physicians, nurses, and engineers to solve problems related to EMR, EPM, and ICS to make software more user-friendly to staff and doctors

Environment: Windows, J2EE, Asp.Net, Agile, Rational Clear Quest, SQL, UML, QNXT, Rational Clear Case, Microsoft office, Word, Excel, Power point

Confidential, Middletown, NY

Business Analyst

Responsibilities:

• Performed usability analysis and testing including user interface design throughout the development life cycle, provided Client meetings.
• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Created Process Work flows, Functional Specifications documents and documented system requirements.
• Provide implementation assessment, strategy, and mentoring services for Rational Rose, UML and RUP.
• Interacted with various cross-functional teams on building business use cases, and understanding expenses and revenue stream.
• Working with clients to better understand their needs and present solutions using structured SDLC approach.
• Interaction with the developers to report and correct bugs.
• Gathered requirements for the inputs in the Competitive Intelligence System from the stakeholder’s including methods like personal interviews, questionnaires, surveys, JAD sessions and joint team meetings. Identified systems requirements that would help create the CI System by meeting up with the technology team and then having a JAD session to include SME’s from the business side.
• Developed the systems implementation project management plan with milestones and steps from procurement of vendors to project implementation and maintenance.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs. Ensured that critical requirements are not missed.
• Aided management in standardizing web applications by preparing GUI standards and recommending alternatives for in corporation in a phased, iterative manner.
• Communicated changes to requirements promptly and precisely to all personnel involved.
• Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.
• Analyzed and translated business requirements into system specifications.

Environment: XML, XSL, Rational Clear Quest, Rational Clear Case, Rational Requisite Pro, Rational Rose, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential, Huntsville, Al

Business Analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Created new database objects like Tables, Procedures, Functions, Indexes and Views using T-SQL in Development and Production environment for SQL Server.
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations
• Created Process Work flows, Functional Specifications documents and documented system requirements.
• Performed all necessary programming, testing and documentation for COBOL, DB2 batch programs and sub-routines.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Extensive involved in Conducting Market Research, Feasibility Studies, Data Analyses, System Analyses, Gap Analyses, and Risks Analyses.
• Develop detailed unit test plans and scripts and conducted rigorous testing per requirements and assisted in data mapping.
• Provide implementation assessment, strategy, and mentoring services for Rational Rose, UML and RUP.
• Interacted with various cross-functional teams on building business use cases, and understanding expenses and revenue stream.
• Performed extensive Requirement analysis and developed use cases and workflows.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Worked with Quality Control Teams to develop Test Plan and Test Cases.
• Interaction with the developers to report and correct bugs.
• Developed Test Plans and Test Cases according to Business Requirements.
• Use HL7 implementation methodology to create specifications, assist with unit testing, and perform integrated testing for messaging between the state Departments of Health and the location office

Environment: Servlets 2.2, JMS, Java2 (JDK 1.3), STRUTS,JDBC2.0, DB2, XML, XSL, XSLT, Rational Rose, PL/SQL, HTML, CSS, JavaScript, Congo’s, HL7, MS Word, Excel, Access, Project, Visio.