SUMMARY:

• 7+ years of experience in business process analysis, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare, Insurance and Service Industry Sectors.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Good understanding of MITA and MMIS functional business areas which include claims, providers services, providers enrollment, recipient services etc
• Experience in Health Care and Insurance industries with solid understanding of Business Process Flows, Case Tools, and Business Analysis.
• Extensive experience in the Implementation of Database maintenance plans, Data Modeling, Data analysis, Data validation, Database Design and creating Report using Crystal Reports.
• Provided GUI manual and automatic testing using WinRunner, and backend validation testing using RDBMS
• Worked with HL7, EDI ANSI 4010 Standards
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Expertise in Software Development Life Cycle (SDLC), Use Cases, Business Process Modeling Notation (BPMN), Object - oriented Analysis and Design, Rational Unified Process (RUP) and Rational tools used during all four phases of RUP: Inception, Elaboration, Construction, and Transition.
• Strong web development and web content management experience.
• Strong knowledge of managed care payer requirements and procedures.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
• Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML), Object Modeling Technique (OMT), Extreme Programming (XP), and Object Oriented Analysis (OOA).
• Process modeling to support systems projects related to the Health Care Management System (CLIO)
• Testing experience includes Data Quality, Integration Testing, Regression Testing, Functional Testing, System Testing, UI Testing and Compatibility Testing.
• Encoded HEDIS 2004, 2005 Medicaid utilization rates for New Hampshire claims data using SAS,R,PL/SQL.
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Used BEA (BPM Tool) to map Process flows and migrated Visio Process flows into BEA Tool.
• Experience in development methodologies like RUP, SDLC, AGILE, SCRUM and Waterfall.
• Expertise in Healthcare- domain. Hands on exp. in HL7 and PACS.
• Implemented automated COB processing of Medicare claims into Facets
• Experience in developing and conducted statewide HIPAA 5010 and ICD-10 awareness program for all IDS staff in Tenet.
• Strong experience in operations,healthcare, information technology, health insurance, legislative and regulatory affairs, marketing, Medicaid Management Information Systems (MMIS), project management and quality assurance.
• Formatted and processed claims for submission on both HCFA-1500 and UB forms
• Familiar with FDA Electronic submission standards and CDISC standards.
• Experience in Forward Mapping and Backward mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes)..
• Market Prominence Implementation for transactions submissions CMS
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, Primavera, Promodel, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Familiarity with Lean principles and Six Sigma methodologies.
• Used Quick Test Professional(QTP) for Automating test scripts for regression suites.
• 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.
• Constant correspondence with clients, claimants, insurance companies, Bill review Status, vendors in regards to outpatient billing claims filed on UB04/HCFA-1500
• Developed and executed White box test cases of the Java classes using TestNG framework & Eclipse .
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.

TECHNICAL SKILLS:

• Rational Team Test, OOAD (OOA/OOD), RUP, UML, Rational Rose, Clear Case, Clear Quest, WinRunner, Load
• Runner and Test Director, C, C++, .net, Java, HTML, J2EE, VB 6.0, SQL, Windows 9x/NT/2000/XP, Facets, Access macros, Excel macros, Active Reports, Unix, Informatica, Six Sigma, Linux, Solaris, Oracle, SQL Server and MS
• Access, TSL, SQL Basic, IBM Mainframe, Shell Scripts, MS Visio, Cognos, MS office, Adobe PageMaker, Adobe PhotoShop,
• MS Project 2002, Adobe workflow systems, Weblogic Server, iRise, Mercury Quality Center, MS Office Sharepoint
• Server 2007,Quick Development Case and Quality Review Tool(QDQ),

PROFESSIONAL EXPERIENCE:

Confidential, Indiana

Business Systems Analyst/ Healthcare Tester

Responsibilities:

• Responsible for the requirement-gathering phase and project plan.
• Responsible for requirements analysis, design and developing technical requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Embrace agile principles. Support iterative user experience design, involving UX research and UX design at all stages of product development
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• Experience with Trizetto Facets 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.
• Used the BPMN to GAP Analysis to bridge the gap between business processes.
• Conduced Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Manages the system support analysts responsible for revenue cycle reporting, WHA reporting, system updates regulatory and contractual, testing upgrades, and testing ICD10 with clearinghouse and payors.
• Participated as a team member supporting and enhancing the Medicaid Management Information Systems (MMIS) for the state of Delaware
• Conducted regular internal and external ICD-10 testing of systems.
• Develop queues assignments and Utilization Management Care Coordinator schedules.
• Helped test throughout new regulatory healthcare requirements.
• Built business requirements into the Medicare Advantage (MA) requirements database and created the Project Requirements Document for the three functional areas
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Review claims for accuracy of all documentation, billing codes and dollar amounts. Submit claims electronically and in HCFA-1500 forms.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in RationalRose for the Business Use Case and System Use Case.
• Conducted the FRS and URS reviews and walkthroughs with designers, developers and stakeholders. Also conducted feasibility and adaptability study.
• Deployed System Development between Epic and Market Prominence
• Conducted JAD Sessions with Infrastructure management team, SME, policy holders and stakeholders for issues which were open and pending.
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Pega Business Process Management (BPM) tool.
• Program in Medical Billing including the use of CPT, HCPCS and ICD9 coding and HIPAA Compliance
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc).
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents. Expert in Configuring and Fine-tuning ETL workflows designed in DTS and SQL Server Integration Services (SSIS).
• Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Created current and future state processes, along with prototype BPM solution at medical device company
• Used the automated tool QTP for Functional Testing and Regression Testing.
• Extensively involved in testing Trizetto Facets and mainly involved in Enrollment and Eligibility modules.
• Performed configuration/ compatibility and user interface testing manually.
• Worked with QA lead in validating Test Plan and Test Scenarios.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual(s) for resolution.
• Member of the systems team and worked cycle model office and production issues which included several different areas of the MMIS.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release
• Documented all testing results and made recommendations for changes and updates.
• Review of high-level design document and low level design of classes and sequence diagrams.
• Ensuring that deliverables were delivered on time as scheduled.

Environment: UML, RUP, Rational Requisite Pro, Rational Rose, Facets, Cognos, Rational ClearQuest, QTP, Excel, SQL, DB2, Crystal Report, HP Quality Center

Business Systems Analyst/ Healthcare Tester

Responsibilities:

• Converted business and user system needs into Vision Documents, Business Process Flows, Use Cases, and Non Functional Requirements
• Conducted user interviews, gathered requirements, analysed the requirements using RUP methodology and documented the requirements using Rational Requisite Pro.
• Followed the Business Rules, and ensured that HIPAA compliant Rules are followed to display minimum benefit information that the Provider is required to pass on the EDI transactions.
• Working within a growing knowledge of F4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, and 278, EDI, Privacy, Security, and Medicaid.
• Reviewed charge master changes to assure HCPCS codes were assigned correctly
• Involved in Six Sigma process analysis.
• Conducted revenue impact testing of systems.
• Performed meaningful use testing procedures.
• Provides consultation to providers on strategies to close gaps in care and reduce fragmentation of care, including leveraging care management staff to impact appointments, medication and treatment adherence.
• Assisted the technical team in translating application functionalities into the application architecture and in producing a System Functionalities Document (SFD); based on gathering requirements and mapping available resources to these requirements.
• Processed HMO, commercial, and liability claims, ability to code CPT and ICD-9-CM proficiently, completed UB04, HCFA-1500, insurance claim forms, Customer service, data entry, charge entry, payment posting, miscellaneous filing, & processing outgoing mails.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Utilized Excel Macros and VBA for automating the process of variance and trend analysis
• Responsible for the use of scarce resources through the development and sharing of reusable software making use of (Medicaid Information Technology Architecture) MITA.
• Analyzed the business requirements and produced a Business Requirements Document (BRD); Linked these BRD requirements to the system requirements using the System Requirements Specification (SRS).
• Followed Agile (XP) Methodology for the release.
• Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates.
• Developed and executed White box test cases of the Java classes using TestNG framework & Eclipse.
• Performed Functional, Regression, Integration and End to End testing using WinRunner.
• Use Test Manager to maintain test cases, ClearQuest to log and track defects, RequisitePro to map test cases with use cases in RUP model.
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Worked with developers and designers of BPM System to make sure development understands business process and detailed technical requirements.
• Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Identified the impacts the HIPPA 5010 & ICD 10 project had on enrollment Claims, FEP (Medicare and Medicaid program).
• Performed regression testing of applications using automation tools like QTP and Win Runner.
• Performed record-playback of applications using QTP.
• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules.
• Experience in configuration of claims adjudication systems, FACETS 4.51/4.71
• Participated in all phases of the Facets Extended Enterprise(TM) administrative system implementation including the planning, designing/building/validation (DBV), testing, and Go-live support phases.
• Analyzed CMS comparison documentation highlighting changes of 5010 format and ICD10 diagnosis and procedure codes.
• Expertise in object oriented analysis and design (OOAD), unified modeling language (UML), use cases, UI development, usage models, layout and wireframes, test cases and user training.
• Interacted with clients and other members of the development and QA teams to ensure delivery.

Environment: IBM Mainframe, MS Access, MS Visio, RUP, OOAD, Informatica,, QTP, Facets 4.51/4.71, Scrum, Agile, MD 3270 Mainframe, MS Excel, COBOL, iRise Studio, Excel macros, Six Sigma, Ultra Edit, Oracle, MS Office, SQL, Windows XP

Sr. Business Analyst/Healthcare Tester

Responsibilities:

• Gathered Requirements, Developed Process Model and detailed Business Policies.
• The SDLC Methodology used was Agile or Scrub
• To Identify all credits and refund appropriate payors and patients
• Conversant in Medical Terminology, HCFA-1500, UB92, ICD-9/10, coding and claim processing guidelines.
• Experienced with internal and external ICD-10 systems testing and analysis
• Highly knowledgeable about testing process automation and implementation
• Gathered functional business requirements from process owners and developed functional specifications for application enhancements.
• Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as, 835 / 837 transactions.
• Re-architected the back-end ETL process supporting the Call Center reporting data warehouse using Microsoft SQL-Server, t-SQL, and SSIS.
• Worked with development / technical team members to ensure that the enhancements would meet the defined business requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Embrace agile principles. Support iterative user experience design, involving UX research and UX design at all stages of product development
• Built a dashboard for the visualization of metadata.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Created customized reports with complex calculations that were used to study the potential financial impacts of changes to Medicare and Medicaid payments.
• 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.
• Acted as a SME for the application team and the Infrastructure team.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Used Requisite Pro for writing/analyzing project vision, goals, specifications and requirements.
• Understanding of healthcare regulations with the ability to use testing within their frameworks
• Good knowledge of automation in repeated regression testing and analysis
• Experience with Trizetto Facets 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.
• Analysis of data and report creation for internal and external customers using Crystal Reports
• Created a variety of IA and UX artifacts. Deliverables included: wireframes (Axure and Fireworks), process diagrams (Axure and Visio), personas (InDesign and Word), prototypes (Axure and hand-coded HTML / CSS / JS), and more.
• Conferred with Business Users to Gather Requirements for the design and development teams.
• Involved in exporting data from the database to flat files.
• Facilitated Joint Application Development (JAD) sessions, as well as conducted interviews of appropriate business/technical stakeholders.
• Analyzed Business Requirements to produce System Requirements for the technical team using MS Visio.
• Good understanding of Health Insurance portability and accountability act (HIPAA)
• Conducted Business meetings for the claims adjudication process and its work flow.
• Identifying and documenting UML Use Cases with Use Case diagrams.
• Work with business users to define Business, Process, and Data Models to understand the overall business.
• Worked with developers to test the iterations of the system under development (SUD) to ensure it met the user’s needs.
• Interacted and assisted the entire team on the testing tools and processes.
• Written and executed Test cases for the application when in (UAT) Environment.
• Involved in evaluation of the user request for new or modified program to determine feasibility, cost and compatibility with current system, and computer capabilities.

Environment: MS Office, Visio, SharePoint, MMIS, UNIX, SQL, Toad, DB2, CMR, Citrix, Rational Suite, Windows 2000/XP.

Business Analyst / Healthcare Tester

Responsibilities:

• Facilitated collection of functional requirements from system users, and prepared business and technical requirement specification documents.
• Facilitated review of Enrollment, Claims, Commissions, and membership portlets’ designs with architects and developers to ensure that the goals of the portal requirements were satisfied
• Used UML, for gathering requirements, created Use Case Diagrams, and Use Case Specification document (USD).
• Tracking and managing requirement changes using Requisite Pro.
• Used Prototyping method to gather additional requirements from the users in order to describe the business needs in terms of the system being created.
• Gathered user and business requirements through open-ended discussions, brainstorming and prototyping
• Developed various artifacts such as use cases, workflow diagrams, business process models and prototypes by interacting with end users, development personnel, project team and the subject matter experts.
• Worked with SQL queries using MS Access for data manipulations.
• Highly skilled with advanced testing methodologies
• Understands and follows R&D compliance standards
• Performs system administration duties related to the content management system (Stellent). This would include developing process flows required for the development of workflows within Stellent that tracks all CMS-mandated content contributions.
• Prioritized project efforts, developed project plans, process flows, Use Cases and SRS using RUP.
• Experience in implementing and managing the implementation of software, hardware and hybrid solutions to enable Electronic Health Records (EHR) and Health Information Exchanges (HIE).
• Used Unified Modeling Language (UML) for process modeling and use cases.
• Implement the business intelligence plan that supports key long-term strategic needs and obtain all resources necessary for their execution.
• Generated daily, weekly, and monthly reports using MS OFFICE Tools and submitted to the Team Leads and Manager for reporting, status reporting and analyzing purpose.
• Successfully implemented AGILE methodology for application development.
• Involved in creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Adopted J2EE best practices and design patterns by using Spring framework.
• Execution of test scripts using WINRUNNER, TESTDIRECTOR.
• Investigated faults within the application and interacted with the development team to resolve technical issues.

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, Rational Requisite Pro, MS Office, SQL Server, Oracle, PL/SQL, Agile, MS Project, MS FrontPage 2003, MS Access, EDI, Documentum 2.0.,UML.