SUMMARY:

• Business data analysis, requirement gathering and Statement of Work (SOW) preparation.
• Performed Project Management GAP Analysis to identify problems and worked closely with Stakeholders and End
• In - depth understanding of the healthcare industry in terms of its structure, administrative processes as well as regulations such as the HIPAA Privacy, Medicare and Medicaid.
• In-depth knowledge of RUP’s Iterative Software Development Life Cycle process i.e., Inception, Elaboration, Construction and Transition.
• Developed various project artifacts like project vision documents, project plans, functional requirements, Statement of Work (SOW), Service Level Agreements (SLA), system glossary, test case specifications, implementation/fallback plans, system training documents and their related traceability.
• Requirement gathering (business/application), vision documentation, UML Modeling, Rational Rose, GAP analysis and MS Visio.
• Working on Government Projects, with C.M.S and Medicare
• Experience in 5010 and HIPAA
• Quality Management and Project Management
• Risk Adjustment and Encounter Data System
• Business Analysis and Project Management
• Expert in Agile and Waterfall Project Management Methodologies

TECHNICAL SKILLS:

Business Modeling Tools: Rational Rose, Rational Enterprise Suite, MS Visio

Requirement Tracking: Rational Requisite Pro, Mercury s Test Director, Mercury Quality Center

Automation tools: WinRunner, LoadRunner, Change Management Tool, TestDirector, Rational ClearQuest, ClearCase, Mercury Quality Center

Operating Systems: MS Windows NT/98/2000/XPWeb Technologies: HTML, XML, ASP, XHTML, CSS, websphere

Databases: Oracle 9i, SQL Server, FoxPro

Methodologies: SEI-CMM, RUP, SDLC, SWOT, Cost/Benefit, Six Sigma White Belt Certified

Frontend Tools: MS Office, MS Project, MS Access, MS SharePoint, CA Clarity PPM

PROFESSIONAL EXPERIENCE:

Confidential,Baltimore,MD

Project Manager

• The Project entails introducing two new student health plans, and implementing the portal to enable users to enroll, compare plans in a HIX environment and pay for the plan. The students will also have a chat functionality to request live help when needed.
• Currently working under VP of account management of CareFirst TPA group.
• Planning highlevel implementation (primary framework) larger scale implementation. Designing a system environment for this product line. Implementing major framework to handle initiatives. Establishing 2 blue plans providing services for Student health plan
• Leading Steering Committee meetings to communicate timelines, risks and milestones.
• Preparing detailed project plan for all phases of the project.
• Reporting schedule, cost and rick status on Clarity every week.
• Managing stakeholder expectations through various workstreams. Including vendor management
• Implemented new clients to the system through facilitating extensive demonstrations, virtual training, and technical support
• Liaised between clients and developers on feature requests
• Proactively addressed potential issues that may affect the system and worked with developers to resolve the matter
• Built solid client relationships by accurately understanding and addressing their needs in a timely manner
• Applied strong facilitation and negotiation skills to lead project meetings, achieve project results and manage vendor relationships.

Confidential,NY

Project Manager

• WebView Implementation - WebView is the interactive portal/user interface version of the IntelliSoft group of applications/ products that will allow existing and providers to complete applications and upload required documents, request privileges, electronically attest and sign their credentialing application and allow non providers to access the database and search for providers and privileges through the internet and intranet.
• Documented the Project Charter and received approval from the Project Sponsor and other Stakeholders
• Managing project meetings and record keeping with Project meeting minutes and action items.
• Developed a Stakeholder register and RACI chart
• Conducted system UAT
• Developed a work breakdown structure and created a clear project schedule
• Developed a detailed project plan and updated as necessary
• Managed project Change Control
• Managed the project SharePoint site and adhered to the standards
• Planned the meetings by providing advanced meeting Agendas and previous minutes
• Kept record of the meeting minutes and action items
• Documented Business requirements
• Managed PPM to maintain project information.
• Defined the new roles and responsibilities for new initiatives
• Identified the Gaps and conducted GAP analysis
• Prepared and delivered reports and recommendations
• Performed vendor management by mitigating risks
• Documented Projects Risks and developed Risk Mitigation plan
• Worked on requirements to implement Websphere integrated platform
• Identifying the right SME’s and persuading them to participate in the project
• Ensured that the Project SharePoint site is up-to-date and versioning of the documents are clearly maintained
• Closely Supported QA team to ensure that requirements were clearly translated to Test Cases/Test Scenarios

Confidential,New York, NY

Project Lead

• Medicare Expansion - Affinity currently operates in the five boroughs of New York City. The expansion project was initiated to expand its operations in the five outer counties of Westchester, Rockland, Orange, Suffolk and Nassau. This expanded coverage entailed inclusion of new providers,Provider credentialing (manual process), benefits and marketing materials.
• Medicare Sales to Enrollment automation - The purpose of this project is to automate the enrollment data collection, eligibility validation and feed to Human Resources Administration. To facilitate this, a database was created internally that supports an interactive enrollment application and is capable to data archival.
• MLTC - The launch of this product was to help people remain in their homes as long as possible and delay use of nursing home and hospital care.
• Prepared business requirements documents and reengineered business processes, used agile methodology.
• Responsible for performing detailed sessions to explain the user requirements.
• Worked on gathering requirements and manually documenting scope for credentialing of providers like licensing. Note: New providers were being added as part of expansion.
• Helped team members in designs, plan and coordination with work teams.
• Developed process flow diagrams using Microsoft Visio.
• Defined and controlled project budgets
• Provided technical supervision to project team members by communicating with the client.
• Responsible for testing web sites and make sure the completion of project before delivering.
• Responsible for designing scope statements, flow of project management and the task management.

Confidential,New York, NY

Lead Business Analyst

• Medicare Renewals 2013, 2011 (Government Projects)- Every year Emblem Health submits a bid to CMS for the new plan year benefits. In addition to the bid, CMS publishes the final Guidance of all the changes that the plan should adhere to, in-order to be compliant with CMS. This project ensures that Claims, Benefits, Enrollment, Customer Service, Medical Management, Sales and Marketing, Vendor Management and Delegates and IT make the necessary changes to ensure compliance with CMS.
• CMS Encounter Data System (Government Project) - CMS is transitioning their R.A.Ps process to leverage the HIPAA x12 ANSI formats for claims and to require submission of all Encounter data elements via the HIPAA version 5010 837-X Format. In this process CMS mandates submission of all adjudicated, unfiltered claims and encounters from all sources including dental (on an 837I /P) as a condition of reimbursement. Additionally, the new required fields, which follow the EDS submittable 5010 format, drastically increase the data for each transaction that is required to be sent for each claim.
• Healthcare Reform (Affordable Care Act) - Emblem Health participated in the health insurance exchange program, by providing fee for service Confidential .
• Member of core team and liaison to the technical team that developed newly automated process for claims, enrollments and billing.
• Planned and managed budgets for multimillion dollar projects aligning business goals and technology solutions, using Clarity as a tool.
• Identified data issues on various vendor files and escalated resolution with external partner, resulting in improved data quality received from the vendor.
• Developed business requirements and mapping documents and assisted with technical requirements for various segments of the project.
• Chaired business user workgroup and coordinated with core team members to maintain communications about project progress and potential impacts of changes to the benef Confidential .
• As leader of claims UAT, worked on configuration testing and determined best way to utilize the functionality of the mainframe system to meet the users’ needs.
• Documented several business requirements documents for the EDS initiative.
• Developed a HIPAA 5010 data map using companion guides.
• Gathered and wrote business requirements for projects dealing with the following electronic HIPAA transactions: Health Eligibility (270/271), Claim Status (276/277) and 837.

Confidential,CA

Business Systems Analyst

• Wrote Functional Designs by going through the Functional Requirements.
• Created business process workflow diagrams (Activity diagrams) in Rational Requisite Pro.
• Involved in analyzing system specifications, designing and development of test plan.
• Authored supporting documents and process flows for business and functional requirements.
• Integrated RequisitePro with Clear Quest and Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests
• Managed all the requirements in RequisitePro, making requirements available to all team members.
• Maintained traceability matrix.
• Tested enrollments and billing functionality extensively for Medicare members on the mainframe system Z/OS (IBM).
• Involved in Test Planning, coordination and implementing QA methodology.
• Participated in weekly team meetings, where test status and defects were discussed.
• Involved in maintaining, enhancing and trouble shooting of the application according to the needs of the customers.
• Adhered to the company policies and guidelines while making Business Decisions and followed PMM.
• Developed UAT testing documentation.

Confidential,Nashua, NH

Business Systems Analyst

• Interacted and arranged meetings with Business and End users to gather business requirements for changes in Medicaid triggered by Government regulations, Medicaid and HIPAA, Business needs and Process improvement.
• Defined Business Process aligns with Company goals and existing HIPAA regulation.
• Involved in this strategy project for assessing HIPAA administrative simplifications/privacy/security compliance
• Worked closely with project manager in setting realistic project expectations and in evaluating the impact of changes on the organization and plans accordingly.
• Received the Client and Business users appreciation for the implementation of Prescribed NPI update.
• Gathered the business requirements and prepared the analyzed data/workflows for business users.
• Analyzed business needs and created Business Requirement Document (BRD), Use Case (UC) documents for business and end user review.
• Translated user needs to business requirements using Unified Modeling Language (UML).
• Worked with the software architects / developers to ensure that the applications conform to customer requirements.
• Prepared Requirement and Business Specification documents and arranged user reviews.
• Maintained Project Glossary for the entire project team.
• Conducted JAD sessions between the end users and the development team.
• Followed a structured approach to organize requirements into logical groupings of essential Business Processes, Business Rules, and Information Needs, thus ensuring that Critical Requirements are not missed.
• Followed the RUP based methodology using Rational Rose to create Use Case, Activity chart.
• Performed Defect Tracking Rational Clear Quest.
• Involved in the peek review of Test Plans, Test Cases with the QA team to verify implementation of new features and enhancements.

Environment: Quality Center, RUP, SQL Server 2000, Java, J2EE, UNIX, Web sphere, Oracle

Confidential,Pittsburgh, PA

Business Analyst

• Coordinated collection of business needs. Converted high level requirements to functional requirements and documented them in functional, navigational and page Use Cases.
• Prepared Functional Requirements documents using the existing templates.
• Documented business rules and functional requirements iteratively
• Developed use cases using RUP methodology for the technical team, which consisted mainly of business rules, which were inherently related to the functions described in the use case.
• Documented technical details in the functional including data source, file formats and data mapping.
• Involved in writing use cases for the portal for Medicare Part A and B as part of HHIC.
• Identified and documented test conditions/scenarios from the business requirements and functional design for DCT, CCC, FCT & FEE for claims processing.
• Involved in systems testing, interfacing of systems, and mapping data based on HIPAA standards or Proprietary layouts.
• Documented requirements and HIPAA compliance issues.
• Experience with the full life cycle of HIPAA Implementation (System Study, GAP Assessment/Risk Analysis, Data and Functional Mapping, Generation Transaction Format, Project Plan, Task report, Documentation and User Training).
• Implemented HIPAA transaction sets, privacy and security regulations for the entire business process.
• Execute test cases/ scripts using Rational Test Manager for system, functional and regression testing
• Assisted the project manager in writing business cases, to verify that this financial tool meets the needs of the business.
• Worked on NPI registry to search for provider information for creating the provider directory. Used ICD-9 for the purpose of classification of diseases for health records.
• Experience with gathering claims data and display of the same; also processing of medical, pharmacy and vision claims as part of the Health Statements project.
• Used Requisite Pro for requirements management to capture, prioritize and manage requirements, which helped in controlling numerous artifacts produced by the teams working on the same project by keeping track of simultaneous update, change notification and multiple versions.
• Actively involved in creating test strategy, conducted manual testing and logged defects using Electronic Project Notebook and Clear Quest. Assisted testing team in understanding the business rules and system development. Created users and user groups to assist testers.
• Executed SQL queries using SQL navigator to gather data elements from Enterprise Data Warehouse. Worked closely with the data analyst to extract data elements needed for medical and pharmacy claims.
• Used UML activity diagrams to depict, business and operational step-by-step workflows. Used MS Visio for advanced diagrams.
• Extensively involved in Confidential Project Lifecycle from initiation to implementation.

Environment: Rational Rose, Rational Requisite Pro, MS Visio, CSS, RUP, SQL, Test director, MS Access, MS Excel, Mainframes, MS Word, HIPAA ( Privacy and Security), Share Point (MOSS 2007) .

Confidential, Minneapolis, MN

Business Analyst

• Interacted with stakeholders and facilitated communication between client and the IT department.
• Involved in creating targeted questionnaires and interviews for SMEs, clients and business users to gather requirements
• Worked as a liaison between business users and developers to submit requirement and changes, clarify questions and issues.
• Created logical and physical data models for each process describing the Input/Output values of each business and functional activity in the diagrams.
• Applied rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI).
• Worked with HCFA 1500 and UB 92 claim forms
• Worked with the following list of HIPAA-EDI Transaction Code sets.
• Worked with HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats
• Experience working with Electronic Claims clearinghouses like WebMD
• Created the user requirement specifications and helped convert them to functional requirements, and assisted the developers with system requirement specifications
• Prepared use case documents and utilized MS Visio to create UML diagrams including use case, activity and class diagrams to extract business process flows and work flows, thereby assisting development and quality assurance teams in understanding the requirements
• Participated in JAD sessions for requirement, feasibility and risk analysis with various stakeholders, including designers, developers, QA and management to identify critical and high risk areas of the application
• Assisted QA teams in developing a user acceptance test plan and test case scenarios to guide a select group of key end-users in testing the user interface and functionality of the application.