SUMMARY:

• 6+years of experience in Business Analyst in the field of Pharma with the strong ability to gather and document Business Requirements, experienced in writing Use Cases, proficiency in SDLC life cycle, understand the workflow concept, ability to gather and document the 'As - Is' and 'To-Be' processes.
• CPT, HCPCS, modifiers, EMR, EHR, Electronic Data Interchange (EDI), HL7, Claims Process and Health Care Payer Environment.
• Good knowledge on UML diagrams, business process flows, business documentation, claims processing &testing and claims adjudication for Medicare and Medicaid, data mapping modeling, Confidential 4.x and medical billing.
• Analyzed and worked with Confidential specific EDI transactions for claims, member enrollment, billing transactions. Worked specifically with 837, 835, 834,
• Good knowledge on Confidential Application mainly Claims Processing Application and Subscriber/Member Application.
• Experienced in gap analysis of Confidential 4010 to 5010 with attention to qualifier, length and required field and situational rules and professional knowledge of HL7 standards.
• Using Confidential for various health insurance areas such as enrollment, member, Products and other Confidential related modules
• Verified and documented Confidential regulator changes found when moving from 4010 to 5010.
• Synthesized 4010 and 5010 Confidential implementation guides related to Claim Testing and Medical Billing.
• Extensively participated in verification of EDI 834 file formats against Standards.
• Solid understanding of healthcare claim process and revenue cycle.
• Experienced in Software Development Life Cycle (SDLC) like waterfall and project life cycle like Agile SCRUM, RUP methodologies.
• Involved in using Confidential for various health insurance areas such as products, enrollment, members and other modules related to Confidential .
• Conducted Joint Application Development (JAD) sessions and interviewed Subject Matter Experts (SMEs) and meeting with clients, teams and other stakeholders for proper requirements gathering.
• Extensively involved in testing Trizetto Confidential and mainly involved in Enrollment and Eligibility modules.
• Expertise in writing Use Cases and producing Use Case Model, Analysis model, Behavior diagrams (Sequence diagrams, Collaboration diagrams) and Class diagrams based on UML Methodology & Business process flow diagrams using Visio.
• Development of UAT, planning Test scenarios to meet the product’s business requirements, and Proficient in both Manual and Automated Testing Techniques.
• Involved in developing and maintaining Requirement Traceability Matrix and Gap Analysis.
• Hands on experience on various testing tools and good command on SQL, SharePoint.
• Experience in data analysis, data validation and data reporting.
• Experience with Trizetto Confidential System implementation, 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.
• Analyzing bugs, interaction with team members in fixing errors and User Acceptance Testing (UAT).
• Experienced in gathering and documenting test Scenarios.
• Worked on Confidential Claims Software System, to convert data from their legacy system (LRSP) and add custom applications to satisfy in-house requirements.
• Excellent Communication, Presentation and Interpersonal skills, Self-starter, Team player with Project Management and Leadership skills.

TECHNICAL SKILLS:

Methodologies: Waterfall, RUP, Agile

Automation tools: QTP/UFT

Defect Tracking Tools: JIRA, QC/HP ALM

Test Management Tools: RALLY, TFS

Healthcare: Confidential

Drawing Tools: MS VISIO, Draw.io

Database: MS SQL Server, MS Access, MySQL, Oracle

Operating System: Windows 7/8/10/XP, MAC, UNIX, LINUX

Programming Languages: C, C++, SQL

PROFESSIONAL EXPERIENCE:

Confidential, Washington, DC

Business Analyst

Responsibilities:

• Gathered, analyzed and documented Business Requirements and created Business requirement documents, Use Cases, Use Case Diagrams, Functional Design documents, Requirement Traceability Matrix and other Project related documents.
• Worked on analysis of Confidential claims processing system and gathered requirements to comply with Confidential 5010 requirements
• Performed business process and systems analysis with a focus on data analysis and process flow diagrams in support of building out current state and future state views.
• Involved in Confidential Implementation, involved end to end testing of Confidential Billing, Claim Processing and Enrollment modules.
• Participated in agile story grooming sessions with the Scrum Master and development teams to ensure that the Product backlog is prioritized as per the criticality of the requirements.
• Conducted business validations covering the following deliverables: Confidential Providers, Confidential claims and Confidential Membership.
• Consulted and recommended future functionality with product management on future functionality based on observed customer workflow needs and customer requests.
• Audited configuration of more than 200 products by running MS- Access queries of Confidential tables to obtain cost sharing information and comparing benefits to configuration.
• Designed and developed Use Cases using UML and Business Process Modeling. Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Worked with providers and Medicare or Medicaid entities to validate EDI 834transaction sets or Internet portals. This includes Confidential 4010; 837, 835, 270/271, 273, 278, and others.
• Worked on Confidential EDI 834Transactions and Code Sets Standards as per the test scenarios such as, 834/ 835 / 837 transactions.
• Participated in solving Billing issues from the Confidential Problem Log for Trizetto and Billing Entities.
• Conducted Gap analysis for the existing system and the proposed system enhancements.
• Supported data replication to and from multiple web sites and maintains the underlying batch processes.
• Tested the changes for the front-end screens in Confidential related to following modules, test the Confidential batches (membership).
• Assisted software engineers and end users with query writing, database access, and general information.
• Tested the changes for the front-end screens in Confidential related to following modules, test the Confidential batches membership, Billing, Provider
• Maintained online analytical processing server and processes to replicate production data to the server.
• Troubleshoot and maintained database encryption.
• Followed Workgroup for Confidential Electronic Data Interchange (EDI) standards for testing that need to comply with the Confidential guidelines.
• Conferred with management and staff on policies and procedures, technical problems, and priorities that relate to database operations. Prepared project status/progress reports on assigned activities.
• Tested all aspects of configuration including unit testing of new configuration, reports and other outputs, Confidential patches and upgrades

Confidential, Rockville, MD

Business Analyst

Responsibilities:

• Involved in all phases of SDLC from requirement, design, development, testing, training and rollout to the field user and support for production environment. Designed, developed, implemented and maintained conceptual, logical and physical data models.
• Performed Data Quality Analysis to determine cleansing requirements.
• Proficiently used Informatica to load data from fixed width and delimited Flat files.
• Overseeing the development, implementation and ongoing maintenance of Confidential 837 (claims), 834 (enrollment),835 (remittance), 276/277 (claims status enquiry and response),278 (referral authorization) EDI 834transactions as required to ensure quality claims.
• Worked with Confidential Team for Confidential Claims Validation and Verification Process (Pre-Adjudication).
• Worked with Confidential edits and EDI Confidential Claims (837/835/834) processing.
• Experience of Confidential in Billing Entity, Premium Rates, Product Billing Component, Billing Group, Fees and Discounts, Adjustments, Claims, Provider, Member.
• Involved in Confidential Implementation, involved end to end analysis of Confidential Billing, Claim Processing and Subscriber/Member module. Set claim processing data for different Confidential Module.
• Complex mappings using corresponding Source, Targets and Transformations like update strategy, lookup, stored procedure, SQL, sequence generator, joiner, aggregate, and expression transformations in extracting data in compliance with the business logic.
• Created SSIS Packages to migrate slowly changing dimensions.
• Worked closely with Data Architect to review all the conceptual, logical and physical database design models with respect to functions, definition, maintenance review and support Data analysis, Data Quality and ETL design that feeds the logical data models.
• Created data mapping documents mapping Source Data Elements to Destination Data Elements.
• Worked on integration workflows and load processes.
• Setting up ETLs to load data into the physical data objects using SSIS and SQL Data Tools.

Confidential, Long Island, NY

Business Analyst

Responsibilities:

• Studied existing business application and processes, collected end user requirements and suggested the improvised business process model.
• Identified the scenarios based on business requirement and Confidential compliance for each transaction such as 837(Claim), 834(Enrollment) and 276/277 (Claim Status).
• Conducted gap analysis and impact analysis of transition from Confidential 4010 to Confidential 5010 on EDI transactions 837, 834, and 835.
• Defined and documented the vision and scope of the project.
• Conducted one on one interviews with high level management team and participated in the JAD session with the SME’s.
• Involved in integration testing on Confidential system to verify Confidential compliance from 4010 to 5010.
• Constructed the Business Requirement Document and the Functional Requirement Document for Inbound (837,835 and 834) and Outbound 271 transactions.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• Worked in association with RUP mentors to ensure fidelity to the standard RUP practices of the institution.
• Set claim processing data for different Confidential Module.
• Design, analyze and performed Integration and wrote System requirements on different leading health care software’s such as Confidential .
• Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: Confidential 270/271,835, 837, 835, 834,820.
• Acknowledged Confidential rules and regulations during Electronic Data Interchange (EDI) and ensured that the development team kept up with it.
• Analyzed Health Plan Enrollment and Maintenance (ANSI X12 834) file specifications under Confidential framework.
• Validate EDI Claim Process as per Confidential compliance.
• Test Confidential regulations in Confidential Confidential privacy module.
• 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 RUP.
• Created and managed project templates, Use Case project templates, requirement types and trace-ability relationships in Requisite Pro.
• Ran the scripts on multiple environments (QA, UAT and Production) to ensure that requirements were still met.
• Performed and coordinated User Acceptance Testing (UAT) with the appropriate group to ensure the correct business logic.
• Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast-changing environment to achieve company goals.
• Provided the management with test metrics, reports, and schedules as necessary using MS Project and participated in the design walkthroughs and meetings.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
• Worked with the clients on the final signing process in the User Acceptance stages.
• Coordinate with Development and Business team to develop high level Business and Technical documents

Confidential, Boston, MA

Business Analyst

Responsibilities:

• Identified the impacts and assisted in training users on new policies / procedural changes.
• Conducted and substantiated JAD sessions with different Business Users to develop new policies and procedures for the Service Catalogue, Charge Capture and Service Work list /Charge Router, Hospital billing, coding, special coding requirements and claim processing.
• Performed GAP analysis between Meditech and Soriano application for the Data Migration and Conversion.
• Developed Use Cases, Test Cases for the Business Users, Developers and QA team.
• Attributed claims processing and payments to third-party providers, monitoring charges and verified correct payment of claims.
• Streamlined and transcribed denial letters on claims followed-up requests for information.
• Identified security risks in medical billing and addressed in requirement document to avoid the security breaches.
• Improvised the new revenue cycle management and Electronic Medical Record (EMR) for Partners.
• Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and271.
• Computed flexible solution for patient treatment plan and patient care plan.
• Designed the tight user authentication and application security.
• Modified existing policies and procedures for patient access such as Enterprise Scheduling, Patient Check-in/Out and Encounter automation.
• Co-ordinate business activities with Subject Matter Expertise (SME) and identify business issues, best practices and performance of other competitors using MS Visio, Performance and Gantt Charts.