SUMMARY:

• 7+ years of experience working as a Sr. Business Systems Analyst in the Healthcare Industry.
• Strong knowledge of SDLC methodologies like RUP (Rational Unified Process), RAD (Rapid Application Development), Waterfall, Scrum and Agile.
• Extensive experience in Unified Modeling Language (UML) diagrams (Use Case, Activity, Sequence) using RSA (Rational SoftArch), Rational Rose and MS Visio.
• Trace and inform business requirement changes through the lifecycle of the project using RDNG, Rational Requisite Pro while maintaining customer needs and maintain a Requirements Traceability Matrix (RTM) to keep the stakeholders informed of the progress of the project.
• Analyzed and synthesized results from Joint Application Development (JAD) sessions and transformed those into Business Requirement Document (BRD).
• Experience in the creation of Test Plan, Test Cases, Test Scripts and Test Procedures based on the Design Document and User Requirement Document for the Black Box, Functional, Usability and User Acceptance Testing (UAT).
• Experience in performing GAP analysis, SWOT analysis, SMART Analysis, Cost Benefit analysis and ROI Analysis.
• A solid background in gathering and documenting User and Business requirements, creating Business Process Flows, Use Cases and Use Case Diagrams.
• Expert in Report Generation and Research Analysis using BI tools like Tableau and Visual Studios.
• Proficient in writing complex SQL queries.
• Working knowledge of R for Data Analytics.
• Proficient in transforming Business requirements into detailed Functional Requirement Specifications Document (FRD) and Use Case Narratives.
• Excellent knowledge of Health Insurance Portability & Accountability Act (HIPAA) standards, 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), EOB(Explanation of benefits/Invoice)
• 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 Test Director 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.
• Excellent Team Building, Project management, interpersonal and communication skills.
• Worked on HEDIS and RDT State mandated reports.

PROFESSIONAL EXPERIENCE:

Confidential, Stockton CA

Intermediate Business Analyst

Responsibilities:

• Work directly with SME’s and Stakeholders and studied various state requirement documents to capture the relevant requirements for the BI team.
• Effectively research, evaluate, and verify all information based on state/federal regulations.
• Worked on HEDIS MY 2017 and various RDT reports to DHCS.
• Created several Data Mapping Documents, BRDs for reporting needs and supported the testing efforts.
• Worked on capturing requirements for RAM (Rate Analytical Model) developed to automate RDT reports.
• Environment MSO 365 suite.

Confidential, Indianapolis IN

Senior Business Analyst

Responsibilities:

• Work directly with SME’s and Stakeholders to gain complete knowledge of the business and its needs.
• Effectively research, verify and evaluate all information based on state/federal regulations.
• Compiled the Vision and Scope Document and composed detailed Use Case Specification Documents in Rational Requisite Pro.
• Prepare Use Cases and flow charts of interaction between different business areas to support mapping of existing data, using MS Visio and PowerPoint.
• Come up with various possible scenarios and questionnaires for stakeholders to effectively capture the requirements.
• Act as a primary liaison between the Client and the Information systems department by preparing technical requirements docs and providing support to testing team.
• Design and prepare various reports using SSRS and BIDs using SQL query.
• Participate in analysis and documenting of data elements and its flow.
• Ensured the accuracy and consistency of the data during the data loading process.
• Design and prepare various reports using SSRS and BIDs using SQL query.
• Involved with E2E implementation and Monitor the trading partner's migration from test to production status
• Worked on Required Traceability Matrix (RTM) in Rational Requisite Pro for traceability of requirements through test cases.
• Act as the main contact with the external trading partners and internal business owner.
• Performed UAT

Environment: MS Office, MS Project, MS Visio, Data warehouse, Cloud based Data warehouse, ReqPro, SSRS RDNG, Agile Environment, windows XP, PowerPoint, Excel, Tableau, SQL server management studio, BI, Visual Studios.

Confidential, Indianapolis IN

Senior Systems Analyst (EDI)

Responsibilities:

• Worked on FEP Confidential and MMIS project, managing the EDI claim.
• Analyze business and user needs, documenting requirements and revising existing systems, maintain organizational Process assets
• Research and report the errors for the failed EDI claims(837/835).
• Ensure that coordinators effectively research, verify and evaluate all information based on state/federal regulations under PPACA.
• Design flows between objects (tables and views) across different layers to support mapping of existing data, using MS Visio.
• Act as a primary liaison between the Client and the Information systems team.
• Contribute and author documents like, BRD, FRD, TRD, RTM and organizational SDLC process documents.
• Participate in writing data mapping documents and performing gap analysis on the systems.
• Create Application Use Case (AUC) documents for business and end user review.
• Developed Test Plan and Test cases for various transactions including, 835, 837, 834 and EOB based on Functional specifications and performed manual testing of the functionality of the application by inserting varying data on different test runs.
• Worked with Business partners on the status of issues, action plans and timeframe for resolution throughout the development cycle.
• Participated in training on SDLC implementation within the organization by preparing various presentation and slideshows using Power Point.

Environment: MS Office, RSA(Rational SoftArchitect), Mainframe, MS Project, MS Visio, Data warehouse, RDNG (Rational Doors Next Generation), windows XP.

Confidential, Overland park, KS

Systems 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 PCP ACA 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.
• Troubleshoot any identified transaction errors.
• 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 XP.

Confidential, Bloomington, IL

Senior 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, Quality Center, MS Project, MS Visio, IBM DB2, Toad, Rational Requisite Pro, Rational Rose, Windows XP, Rational Clear case, Rational Clear Quest, Rational DOORS, IBM Optim Query, Win SQL.

Confidential, Tampa FL

Business Systems Analyst

Responsibilities:

• Worked closely with the development team to clarify/understand functionality and ensure that the developers clearly understood the business requirements that the system was designed to fulfill.
• Implemented RUP methodology for iterative and incremental development of the system.
• Researched and understood the software interfaces, coding changes and overall impact on claims adjudication and reimbursement systems due to ICD-9 to ICD10 transformation.
• Performed GAP analysis to identify AS-IS a process of claims transactions of (ASC) X12 4010A standard and TO-BE processes of (ASC) X12 5010 standard.
• Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables.
• Facilitated JAD sessions for Requirements gathering between the various departments dealing with claims processes to gather requirements for the upgraded system.
• Designing Functional Specifications for the target physical database.
• Analyzed Business Requirements performed Gap analysis and segregated them into high level and low level Use Cases, Activity Diagrams using Rational Rose.
• Developed, reviewed, understood and validated Testing scenarios/script and Defect Tracking with Quality Center. Also developed Test plan and Test cases based on Use cases and Functional Specifications.
• Develop Mapping rules, Design specifications and Use Cases for the HIPAA 4010-5010, 837i/p/d; 270/271, 276/277, 835, 824, 275 and others. Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277). Create EOB systems (835).
• Conducted Brainstorming and Facilitated Joint Application Development (JAD) session.
• Prepared Business Requirement Documents, Functional Requirement Document, Non-functional Documents from the gathered requirements.
• Adopted AGILE methodology throughout the project.
• Maintained the Traceability Matrix to trace the identified business requirements against functional requirements to use case.
• Worked on mapping of ICD9-ICD10
• Acted as a liaison between the Managed Care Organizations (MCOs)/Medicaid providers and the development team in gathering requirements.
• Maintained and submitted periodic/monthly status reports to the Program Manager to serve as the team’s assessment of the project and its schedule.
• Reported progress against Development/Action Plan routinely to the Program Manager with recommendations for corrective actions, where necessary.
• Maintained a Requirement Traceability Matrix to ensure that all Functional Requirements are addressed at the Use Case Level as well as the Test Case Level.

Environment: MS Office, Quality Center, MS Project, MS Visio, Oracle, Toad, Linux, Rational Requisite Pro, Rational Rose, Windows. Windows, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), MS Access, MS Project, Rational Rose, Community Manager, BPML, SQL, Clear Case, RUP.