SUMMARY:

• Over 6 years of experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.) HL7, Eligibility and Benefit systems, ICD 10, HCPCS, CPT, HIPAA 4010 and 5010, Claims Adjudication and expert in Affordable Care Act (ACA), aka Healthcare Reform (HCR)
• Having extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, ICD 10, System, Medicare and Medicaid, CMS Compliances/Regulations.
• Strong understanding of Relational databases, Data Warehousing, ETL, fact and dimensional model and Business Intelligence - Reporting with experience in the life sciences and healthcare domain.
• Involved in Processing EDPS, RAPS, and Reconciliation Reports (Recon Reports)
• Strong institutional knowledge of Medicaid; including Medicaid Information Technology Architecture (MITA), and Medicaid Management Information Systems (MMIS)
• Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrollment, 835 Claim Payments, 829, 270-278 and many other healthcare maps.
• Understanding of EDI business practice and the ability to understand the client's needs.
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
• Extensive knowledge of EDPS errors which includes 254, 19, 255, 465etc., also include RAPS Errors 450, 451, 455, 400, 500 etc.
• Working experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS/RAPS).
• Experienced with Federal contracts, X12 transactions, health care act, EDI transactions 270, 271, 834, 835, 837.
• HIPAA related EDI development for 837, EDPS, 835 and other EDI processes using Pervasive EDI translator.
• Wrote BRD, TSD, Mapping doc., test scenarios, test cases for testing the functional and non-functional aspects of both ETL and Reporting jobs.
• Worked on different EDI healthcare transactions like 834-Benefit Enrollment and Maintenance and 820-Payment Order/Remittance Advice.
• Extensive experience in all platforms of invos/open text EDI mapping software including trusted link, Biz Manager and Biz Mapper.
• Also 5010 Upgrade mapping for new B2B and existing B2B clients.
• Involved in Facet Implementation and conversion of 4.21 and also in TriZetto Facets and TriZetto HIPAA Gateway 4.11.
• Conducted internal audits and prepares audits reports to ensure compliance with Medicare, Medicaid and other institutions.
• Background of documenting HL7 and X12 interface specifications.
• Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR (continuity of Care Record), CCD (Continuity of Care Document), NCPDP Script 8.1, ELINCS, and CDA, HHS, CMS, RHIO's, IHDN's.
• Expertise in Membership Enrollment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis.
• SQL application management, (added users, created backup and recovery plans, ran SQL scripts)
• Thorough knowledge of ICD-9, ICD 10 codes and CPT codes for both Mental and Medical Health.
• Exceptional knowledge in testing phases with state HIX projects.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Experience as developing, building and maintaining data warehouse.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Scrum and Agile.
• Operated Visual basic on different operating systems such as Windows and UNIX.
• Great attention to detail while understanding big-picture objectives and strategy
• Excellent experience in developing and executing Test Procedures, Test Cases, Test Scripts, Test Plans, performing Functional Testing, Compatibility Testing, Usability Testing, Stress Testing, UAT.
• Knowledge in the ETL (Extract, Transform and Load) of data into a data ware house/data mart and Business Intelligence.
• Understanding of developing reports, dashboards, and processes to continuously monitor data quality and integrity on Salesforce.
• Strong understanding of management techniques intended to improve business processes like Six Sigma.
• Good knowledge on the different systems like policy admin, cash, print, and claims. Ability to resolve complex issue in a short time within the SLA.
• Highly motivated and initiative to learn new tools, and research new concepts, ideas, and technologies quickly.
• Strong systems/process orientation with demonstrated analytical thinking, organization skills, and problem-solving skills, willingness to train and teach others. Good interpersonal skills and ability to interact with clients.

PROFESSIONAL EXPERIENCE:

Confidential, Basking Ridge, NJ

EDI Business Analyst

Responsibilities:

• Performed SWOT and Gap analysis for the new functionality requirements
• Developed and supported the ETL process for the data warehouse from various data sources including EDW.
• Responsible for data management, submission and reconciliation as well as analyzing and reporting for Medicare and Medicaid RAPS and EDPS risk adjustment programs.
• Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Functioned as a CMS point of contact for whole RAPS and EDPS claim submission process, which include tracking all claim submission, return file management, regulatory documentation distribution, maintaining clear communication etc.
• Worked on RAPS and EDPS reconciliation change requests.
• Responsible for validating claim processing transaction of MMIS.
• Worked on the ETL implementation using SQL Server Integration Services (SSIS).
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Worked on different types of insurances such as, Group health insurance, individual health insurance, dental insurance, vision insurance, etc.
• Hosted the application online using Microsoft SharePoint excluding some functionality those were developed to use by employees only.
• Identified and documented the dependencies between the business processes.
• Created and executed Use cases for product and benefits testing for Medical and Dental.
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Responsible for Medicaid Claims Resolution/Reimbursement for state health plan using MMIS.
• Conducted JAD sessions and Data modeling.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment.
• Determine member benefits and priced claims according to individual provider's contract under Medicare CMS guidelines and Dental benefits
• Facilitated daily scrum, sprint planning and sprint retrospectives meeting.
• Diverse experience in Information Technology with focus on Business Analysis, Business Modeling, Requirement Gathering, Documenting Requirements (BRDs/FRDs/Use Cases), and Software Validation.
• Worked with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Documented all the aspects of Systems validation lifecycle in accordance with the FDA regulations, including Validation Plan and Protocol, Installation Qualification (IQ) Specifications, Operation Qualification (OQ) Specifications, Performance Qualification (PQ) Specification.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology)
• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Responsible for teaching sessions for end user to tell how to use tools.
• Used MS Project for various planning and budgeting activities.

Confidential, Virginia Beach, VA

Business Analyst/ EDI Analyst

Responsibilities:

• Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, implementation and testing for processing of Medicare, Medicaid and Tri-care claims.
• Involved in the initial discovery/analysis phase for projects to determine the scope and impacts to the data warehousing systems.
• Worked with the team on FACETS claims processing system and gathered requirements to comply with HIPAA.
• Produced BRDs and FRDs for RAPS and EDPS process to automate return file management process and achieved accomplished efficiency in saving processing time by 95%.
• Set claim processing data for different Facets Module.
• Involved in integration of FACETS with legacy and third-party vendor applications.
• Establish documentation for Agile methodology for implementation with a very water-fall-centric development team.
• In depth Understanding of HIPAA X12 EDI transaction 834 for enrollment and eligibility, X12 EDI transaction 820 for Payment Order/Remittance Advice, Acknowledgement transactions 999 and TA1.
• Performed analysis of enrollment and eligibility data in the XML format to determine if data is compatible with X12 data.
• Created 834 X12 format using Edifecs Specbuilder and Note Pad ++.
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Responsible for the core activities of the test team including creating and executing test cases, analyzing and documenting results and drawing a traceability matrix to match the requirements with the final test scenarios.
• Worked on report creation skills using Microsoft SQL Reporting Services (SSRS)
• Participated in release cycles of software developed using Waterfall and Agile methodologies.
• Integrated various systems with HEDIS and create design for HEDIS and other systems to pull data in HEDIS.
• Assists with TRR and MRR reconciliation, along with the investigation, correction, and tracking of enrollment transaction
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS and EDI
• Proficient in writing SQL queries for testing and data validation.
• Develop, test, modify and manage EDI (x12 standard) maps using B2B mapping tool in the Healthcare industry.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Employed UML methodology in creating UML Diagrams such as Use Cases, Sequence Diagrams, and State Diagrams, Activity Diagrams and business process and workflows.
• Strong experience working in Software Development Life Cycle (SDLC) using various methodologies including Agile, Waterfall.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Evaluated and performed testing within Facets for Rejected QA Scenarios.
• Worked on Member Management, Eligibility, Claims and Billing modules within FACETS.

Confidential, Louisville, KY

Business Analyst/EDI Analyst

Responsibilities:

• Analyzed existing business units, business/Application and their Interfaces with their capability through open-ended discussions, brainstorming sessions, and prototyping, prioritizing them and converting them as business requirements that must be included while developing the software.
• Created Data Flow Diagrams (DFD's), ER diagrams for data modeling and web-page mock-ups using MS - Visio for acceptance from end users.
• Experience in Data Warehousing; responsible for data mapping activities including maintaining mapping
• Analyzed data and created reports using SQL queries for all issued Action Items.
• Generated test cases in Claims Analyzer Editor Professional to ensure unification with CPT-4 and ICD-9 codes
• Experience working with ETL specifications and ANSI X-12 data translations
• Define business requirements and business process and policy changes related to the client Medicaid system during the conversion from the existing HIPAA 4010A formats to the future HIPAA 5010A format
• Analyze and document Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Converted the XML files into X12 and X12 to XML files on GIS for sending and receiving the EDI files.
• Also worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277)
• Responsible for the development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837 and 5010.
• Reviewed the application systems and determined how to map the new applications data to the EDI System.
• Create EDI interface to send purchase order requests and receive acknowledgments and invoice data.
• Mainly assisted with documenting processes, used agile methodology to write the System Requirements documents and designed Functional specifications.
• Conducted UAT. Wrote SQL queries in MS Access and Oracle for data manipulations.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Proficient with QNXT claims processing platform.
• Developed Use Cases, Use Case Diagrams, UML Diagrams, Activity Diagrams, Sequence Diagrams, Class Diagrams in Rational Rose
• Utilized RUP to configure and develop process, standards, and procedures.

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Gathered requirements and prepared business requirement documents (BRD)
• Responsible for translating BRD into functional specifications and test plans.
• Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Created and maintained data mapping document (s) in reference to the claim process transactions.
• Involved in processing the claims to ensure claims are being processed correctly
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to define the Data Process Models.
• Involved in /EDI transactions Analysis, Design, Implementation and Documentation.
• Reviewed in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Maintained Requirement Traceability Matrix (RTM)
• Presented the nursing outcomes to C-Level executives in Gentiva Nursing and Data Management group using Crystal Reports XI.
• Use Case development using modeling tool MS Visio.