SUMMARY:

• Over seven years of professional experience as a Sr. Business Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs
• Highly motivated, organized and results and detail oriented with excellent interpersonal, communication and presentation skills. Proven capability of adapting to new and fast changing technologies.
• Strong knowledge of SDLC methodologies like RUP (Rational Unified Process), RAD (Rapid Application Development), Waterfall, Scrum and Agile.
• Analyzed the results in JAD (Joint Application Development) sessions and clearly defined and documented them in Business Requirement Document (BRD).
• Strong knowledge in writing and creating test plan, test cases, test scripts and test procedures based on Design Document Specifications (DDS), AND User Requirement Document for Black Box, Functional, Usability, and User Acceptance Testing (UAT).
• Well - experienced in performing AS-IS and TO-BE documents using GAP Analysis, and can perform SWOT Analysis, Cost Benefit Analysis, and ROI Analysis.
• Excellent knowledge in Defining, Gathering, Analyzing, and Documenting the Business, Functional and User Requirements. Also, creating Business Process Flows, Use Cases and Use Case Diagrams using MS Visio.
• Experience in writing complex queries using SQL for AdHoc Report Generation and Research Analysis.
• Excellent knowledge of Affordable Care Act (ACA/PPACA) and experience with HIPAA compliance.
• Electronic Data Interchange (EDI), HL7 and ICD-9 to ICD-10 coding.
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Extensive knowledge on the various health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO (Preferred provider organization), HMO (Health maintenance organization), and POS (Point Of Service).
• Knowledge of MMIS (Medicaid Management Information System), HIX (Health Insurance Exchange), EMR (Electronic Medical Record), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA), Emergency Medical Treatment and Active Labor Act (EMTALA)
• Working knowledge of Bug Reporting Tools like QTP and Quality Center.
• Experience in working with Project Managers, Project Sponsors, and Service Managers to support project administration and manage the scope.
• Expert level skills in MS Office products like MS Word, MS Excel, MS Project, MS Visio and MS PowerPoint.

TECHNICAL SKILLS:

Project Methodologies: SDLC, Agile, Rational Unified Process ( RUP ), UML, Scrum

Business Modeling Tools: Rational Clear Case, Rational Clear Quest, Rational Rose, Rational Requisite, MS Visio, UML, XML, Rational Requisite Pro

Operating Systems: Windows All OS, UNIX, LINUX, MACOS

Database: SQL server, Oracle, DB2

Quality Assurance: HP ALM/Quality Center, JIRA

Business Applications: Microsoft Office Suite, MS VISIO, MS Project, Use Case Modelling, GAP Analysis, Root Cause Analysis, SWOT Analysis, BRD, FRD, SRS, HIPAA X12 Transaction Codes

PROFESSIONAL EXPERIENCE:

Confidential, Overland park, KS

Sr. Business Analyst/ EDI Analyst

Responsibilities:

• Interacted and arranged meetings with Business and End users to gather business requirements for changes triggered by Government regulations and HIPAA, Business needs and Process improvement.
• Drive modification to any EDI transactions maps as required by Trading Partners.
• Worked on Medicare, HIX (ACA/ Obama Care) ICD-10 implementations, Health Assessment Systems, HL7 Standards, HIPAA, EDI.
• Analyzes business and user needs, documenting requirements, and revising existing systems.
• Ensure that coordinators effectively research, verify and evaluate all case information based on state/federal regulations under the Affordable Care Act (ACA).
• Designed flow between objects (tables and views) across different layers to support HIX data by using MS Visio.
• Acted as a primary liaison between the Client and the Information systems department.
• Tested HIPAA Transactions and Code Sets Standards such as 820, 834, 837/835, 270/271, 276/277 transactions.
• Wrote functional and technical requirements to support development and testing efforts for PPACA project, MA migration.
• Research system issues through HIX to determine root cause relating to eligibility determination errors, monitor trends within appeal process to identify potential system problems.
• Participated in writing data mapping documents and performing gap analysis on the systems.
• Managed data flows and systems configurations for EDI 834 and 820 processing.
• Analyzed business needs and created Business Requirement Document (BRD) Application Use Case (AUC) documents for business and end user review.
• Worked on Facets UMI Process for Medicare Migration and Existing Vendors.
• Manage test file trading with external Trading Partners (Clients / Payers, Providers, Clearinghouses).
• EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (820, 834, 837P, 837I, 837D, 270/271).
• Coordinate with IT any EDI map customizations, including assistance with Design and internal testing
• Analyzed system requirements and developed detailed Test plan and Test cases for EDI Testing.
• Dealt with ETL (extraction, transformation, and load) processes using Oracle and Database.
• Monitor the trading partner's migration from test to production status
• Communicate testing status to the appropriate business process owner and Trading Partner contacts.
• Worked with various ETL tools for the generation of data marts for reporting purpose.
• Act as the main contact with the external trading partners and internal business owners related to EDI questions.
• Maintain the transaction specific Companion Guides
• Stay current with HIPAA EDI regulations.

Environment: MS Office, Quality Center, Facets, MS Project, MS Visio, Oracle, Toad, Linux, ETL, Data Warehouse, Rational Requisite Pro, Rational Rose, Windows.

Confidential, West Sacramento, CA

Sr. Business Analyst

Responsibilities:

• Involved in gathering, analyzing, documenting, and verifying business requirements.
• Organized JAD Sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system.
• Design and review of various documents including the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM), and testing documents.
• Lead business analyst for collaborating requirements from CA, MT and NY state Medicaid system used JIRA as a tool to manage the requirements.
• Familiar in reviewing the legacy system and MMIS system documentation.
• Regression Testing of Web applications and applications dealing with MEDICAID and MEDICARE Services.
• Involved in preparing the Automation Design document and framework with the automation team through BPT module of HP ALM/Quality Center.
• Worked closely with stakeholders and SME’s for requirements gathering.
• Involved in Requirements validation for ICD 9and ICD 10.
• Developed and executed test cases test Scenarios and followed-up defects using HP ALM/Quality Center.
• Checked the page text, titles, and forms for ADA compliance.
• Generate all Medicare claims review and transmits to Medicare.
• Worked as team lead and addressed the items in timely manner.
• Developed and executed UAT test cases, UAT test Scenarios using HP ALM/Quality Center and followed-up defects using JIRA.
• Worked on developing the business requirements and use cases for Facets batch processes; automating the billing entity and commission process.
• Extensively interacted with the QA Team in executing the Test Plans, Providing Test Data, Creating Test Cases, and Issuing MR upon detection of bugs and collecting the Test Metrics.
• Wrote Use cases and test cases for testing and the processing of member enrollment and benefits.
• HP ALM/Quality Center was used to create the test plan, store test cases, and run the test sets.
• Performed “UAT” for 5010 and ICD 9and ICD 10 codes.
• Involved in the testing of web portal of New MMIS system.
• Utilized Defect module of HP ALM/Quality Center for Defect Management.
• Followed the RUP methodology for the entire SDLC.
• Using MS-Visio analyzed business requirements and process through Use Cases, Class, Sequence, and Activity diagrams, and adapted UML standards to define modularized Data Process Models.
• Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
• Developed a Business Acceptance testing strategy and plan.
• Created test files and analyzed test results using MS-Excel.
• Created a User Guide and Operations Guide for the Annuities Group and IT.
• Used HP ALM/Quality Center to report and track bugs and impediments.
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Coordinated and facilitated the execution of User Acceptance testing.

Environment: MMIS, Tortoise SVN Repository, SDLC, Agile, Windows, MS Visio, HP ALM/Quality Center, XML, Jira, Web Services, UAT, HIPAA, MS Project, SQL, Oracle, MS Office suite, etc

Confidential, Bloomington, IL

Business Systems Analyst

Responsibilities:

• Worked with Business community, Stakeholders, SME’s and Systems to define business requirements and analyze the functional requirements.
• Implemented RUP methodology for iterative and incremental development of the system.
• Facilitated JAD sessions with management, users, and other stakeholders to define the project scope and requirements as well as to reduce the time-frame required to complete deliverables.
• Conducted extensive R&D and impact analysis on all the areas affected due to ICD-9 to ICD10 transformation.
• Performed GAP analysis to identify AS-IS processes of claims transactions of (ASC) X12 4010A standard and TO-BE processes of (ASC) X12 5010 standard.
• Prepared and presented Business Requirement Document (BRD), and Architectural Decision Document (ADD) and involved in sign-off process.
• Worked with Facets team for HIPAA Claims validation and verification process (Pre-Adjudication).
• Managed day-to-day project activities and coordinate tasks with other teams through the SCRUM meetings.
• Analyzed high-level business requirements to create Use Cases and Use case diagrams using Rational Rose according to UML methodology.
• Created Screen mock-ups to elicit new requirements and align them around project scope using HTML and MS Visio.
• Data mapping, logical data modeling, used SQL queries to filter data within the IBM DB2 database tables.
• Designed Functional Specifications for the target physical database.
• Developed and validated Test scenarios/scripts and Defect Tracking with Quality Center and TRAC. Also, developed Test plans and Test cases based on Use cases and Functional Specifications.
• Provided support for User Acceptance Testing with UAT plans and resolving any issues with the users, performed UAT and developed different testing strategies for Black Box and Load testing.
• Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277). Create EOB systems (835).
• Conducted SMART analysis and facilitated Joint Application Development (JAD) sessions to resolve issues.
• Adopted AGILE methodology throughout the project.
• Responsible for managing the System Requirements and Requirements Traceability Matrix using Rational Requisite Pro.
• Worked on mapping of ICD9-ICD10
• Reported progress against Development/Action Plan routinely to the Program Manager and leadership with recommendations for corrective actions, where necessary.

Environment: MS Office, HP ALM/Quality Center, MS Project, MS Visio, IBM DB2, Toad, Rational Requisite Pro, Rational Rose, Windows, Rational Clear case, Rational Clear Quest, Rational DOORS, IBM Optim Query

Confidential, Augusta, ME

Business Analyst

Responsibilities:

• Analyzed the existing Claims Direct Data Entry (DDE) application
• Assisted Project Management and other business services departments in planning, implementing, and monitoring complex projects.
• Worked on projects in the Coordination of Benefits department utilizing the MS Access.
• Conducted gap analysis between the current system and new requirements to be implemented thereby mapping the business requirements to the application
• Assisted in preparing Scope Document by analyzing - various business domains interdependencies, end to end business processes of claims adjudication, various business domains scope statement, current business process flows and current system documentations.
• Prepared high level and detailed system requirements documents for the application
• Involved in daily Scrums to determine the status of the project and impediments, if any.
• Involved in sprint planning meeting to identify the tasks for the sprint and getting team members acceptance/commitment for the assigned tasks.
• Involved in Sprint review meeting with the team and stakeholders to review the achievements from the sprint and get approvals.
• Identified the requirements that go in each sprint, collect them in the sprint backlog and collecting and managing the requirements that are not part of the current sprint into the product backlog.
• Designed the Internet based application and managed the business and design specifications in the business specific wikis.
• Write high level and low level business requirements and design mock-up screens for the application
• Analyzed the existing data model and provided suggestions and recommendations
• Validated the requirements and mock-up screen designs of new GUI for internet based application with the product owner and other stakeholders
• Worked for the team that was responsible for converting the programs from 4010 to 5010 versions for HIPAA standards, there was also included the NCPDP conversion for drug claims.
• Conducted meeting with the team members to discuss the requirements and mock-up screens
• Wrote user stories and acceptance criteria for the requirements of the project.
• Involved in daily scrum meeting to discuss any roadblocks or impediments in the project path
• Involved in sprint planning session to identify the features and functionalities that should be achieved by the new application
• Identified various points of integration among the new and existing applications and required integration with other IT components
• Worked closely with the business team, development team and the quality assurance team to ensure that the application will achieve desired functionalities
• Provided business and technical suggestions and recommendations during the project life cycle.

Environment: Windows, MS Visio, Quality Center, UAT, SDLC, Agile, HIPAA, MS Project, SQL, Oracle, MS Office suite, etc.