SUMMARY:

• 6+ y ear s o f di v ers e ex p erienc e as a Bu sin ess Syste m An al y st in de v elop in g an d im p lem en tin g inn ov ati v e bu sin ess p ro c esse s .
• 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.
• Fun ctio n al e xperienc e in h ealth Care Indu stry with v a st kn o wledg e o n M edic are an d M edi caid .
• 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 g o f I C D -9 -CM an d I 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 2 Stand 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.
• Exc epti o n al ab ility to m ain tain an d bu ild clien t relati o n ship s with bu sin ess o wn ers to id entify, p ri o ritiz e an d d o cum ent bu sin ess re qu ire m ents.
• Experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and
• 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.
• Experience with Trizetto’s QNXT4.8 -good knowledge of all Trizetto’s QNXT modules
• Knowledge in creating prototypes and mock-ups for user interface designs.
• Knowledge in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets
• Experience in Business Requirement and System Specifications Analysis.
• Specialized in creating UML Diagrams like Use Case, Activity and data flow diagrams using Rational Rose and MS-Visio and consistently translate business requirement into IT solutions.
• Extensive knowledge of reporting tools such as SQL and ACCESS for underlying database tables and resolve data issues.
• Knowledge in RDBMS concepts and running SQL queries.

TECHNICAL SKILLS:

Technologies/Tools: MS Project, Visio, Excel, Word, Outlook, PowerPoint, iRisestudio, QNXT

RequirementsManagement: RationalRequisitePro

BusinessModeling: RationalRose,MS Visio

DefectTrackingTools: HP QualityCenter, Rational ClearQuest

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

Methodologies: RationalUnifiedProcess(RUP),Agile,Waterfall

PROFESSIONAL EXPERIENCE:

Confidential, Amherst, NY

Business System Analyst

Responsibilities:

• Responsible for participating in the design sessions, reporting on project progress and identifying potential risks and issues.
• Prepared requirements documents for conversion of 834 401 0 to HIPAA compliant 5010.
• Involved in claim adjudication process of facets application
• Involved in processing of the claims on Trizetto’s QNXT and then sharing the test result with the business according to test acceptance criteria during the UAT phase
• Planned and conducted elicitation based on EDI 834 requirements.
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Validated claims using Trizetto’s QNXT claims processing system
• Worked on Trizetto’s QNXT subsystem such as billing and enrollment
• Wrote requirements on how Trizetto’s QNXT system validates different claims
• 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.
• 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.
• Providing content to and for collaboration with training staff on training stake holders on the transactions and the reconciliation process.
• Training other analysts on the transactions and on the reconciliation process.
• Participating in all phases of testing and working through document issues.
• Working the technical and development team to resolve identified issues in a timely manner.
• Direct knowledge and experience with the following elements ANSI X 12 401 0, EDIFACT, Multiple VAN’s Gentran /GIS.
• Reviewing documented training material for accuracy and assisting in end user training and support.
• Responsible for accomplishing business objectives by identifying and solving customer information and processing problems.
• Created XML configurations to accurately parse EDI, EDIFACT, CSV, and Excel data files into the Info Now Oracle database
• Applying triage, research, collaboration and technical knowledge to resolve transaction and processing issues with the use of supporting technology such as work flow management systems and case management software.

E n v i r on me n t: Qua lity C enter 1 0 .0, MS Visio, IB M D B2, Syba se, M S MS Word, Outlook, M S Vi si o, Trizetto’s QNXT 4.80, SharePoint, Microsoft SQL Server 2005

Confidential, DE

Business System An a l y st

Responsibilities:

• Gathered business requirements through discussion with stake holders and SME’s.
• Performed Gap Analysis for HIPAA 5010.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 99 9 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• 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 40 10 and 50 10 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
• 40 10 to 501 0
• Worked extensively on EDI transactions 837 and 83 5 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.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintainace), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).
• 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.
• Performed parallel testing for the 83xtransactions to ensure comparable results between 40 10 and 50 10 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.
• ConstantlyinvolvedinreviewmeetingsandmadesuretestingisdonebasedontheQAmasterplanand deadlines are met.
• 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, M i cro s o ft SQL S erve r 2 0 0 5, Qua lity C enter 1 0 .0, IB M D B2, Syba se,M S W o rd and M S Exc el

Confidential

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

Responsibilities:

• 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).
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
• Worked on Health care Eligibility and Benefit, Claim Status transactions 270/271, 276/277, 835, 837 based on the HIPAA compliant ANSI X 12 version 40 10/5010
• 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 10.0, 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.