SUMMARY:

• 8+ years of experience in Business Requirements Modelling, Business Process Analysis, Data Analysis, and Client/Server applications for enhancing the business processes in diverse business domains.
• Extensive working experience in agile SCRUM environment with diverse teams.
• Experience in SDLC, Agile, Waterfall, Rational Unified Process, and SCRUM software development methodologies.
• Have knowledge of HL7 Messaging protocols, HIPAA transaction and code standards and electronic data interchange (EDI) standards like X12 837, 270, 271, 276, 277, 278, 835, 275 and knowledge of claims encounters process.
• Experience with health care systems: QNXT, FACETS, Medicare Part A, B, C, D, Medicaid systems, and validating General Equivalency Mappings (GEMs), Technical Report Type 3 (TR3) Implementation Guide, and Companion Guide.
• Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing.
• Experience in Release planning, Acceptance criteria, definition of done, definition of ready, Potentially Shippable Product Increment (PSPI), minimum viable product (MVP), and good understanding of test driven development.
• Used tools like JIRA and RALLY to create and maintain Product Burn - down chart, Sprint Burn-down/ Burn-up chart.
• Possess skills like Conflict Resolution, Sense Making, Root Cause Analysis, Risk Analysis, Communication Management, problem management, Stakeholders Management and having Servant-Leader leadership skills.
• Proficient at coordinating with stakeholders, vendors, Subject Matter Experts (SMEs), Project Manager (PM) and end users and elicitation of requirements through Joint Application Design (JAD) sessions, Brain storming sessions, interviews, Surveys and questionnaires, prototyping, benchmarking, Requirements workshops, focus groups, document analysis, Joint Application Requirement (JAR) sessions and Rapid Application Development (RAD).
• Skilled in gathering and converting User Requirements into High Level and low level documents (HLD/LLD) like Business Requirements (BRD), Functional Requirement Documents (FRD), Functional Requirement Specifications (FRS) System Requirement Specification (SRS),and visualizing graphical user interface (GUI) using mockup screens.
• Expertise in Gap Analysis, SWOT analysis, risk analysis, cost-benefit analysis, feasibility analysis, and impact analysis.
• Worked on UAT testing and took signoff from the Commercial line of Property & Casualty business users.
• Experienced in creating workflow analysis and design, Process re-engineering, process remodelling, Object Modelling Technique (OMT), Object Oriented Analysis (OOA),Unified Modelling Language (UML) diagrams like activity diagrams, sequence diagrams and use case diagrams through MS Visio, What-IF scenario analysis (WISA), To- Be Scenario Analysis, Gap Analysis, User Interface (UI) design, User Experience design (UX), prototypes and wireframes.
• Managing Requirement Traceability Matrix (RTM),Service Level Agreement (SLA) and assisted Project Manager with creating Work Breakdown Structure (WBS),Project proposal and Project charter, Statement of work (SOW).
• Proficient in creating and managing Use Cases, User Stories, Test cases, Test plans, Test reports, Test scripts.
• Skilled at performing User Acceptance Testing (UAT), handling Change Request, and Configuration management.
• Strong knowledge of creating conceptual data models, ER diagrams, data mapping, data profiling, data verification, data integrity, ETL process, data normalization, data dictionary, SQL queries for data analysis and data validation.
• Experience working with managed care plans, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans, Coordination of Benefits (COB), Explanation of Benefits (EOB).
• Experience in configuration of claims processing applications, claim adjudication process, claims management process, real time claims adjudication, Electronic Medical Records / Electronic Health Records (EMR/EHR) and Medicaid Management Information System (MMIS),and Medicaid Information Technology System (MITS).
• Good knowledge of COBRA insurance, claim submission process for CMS-1500 (HCFA-1500) and UB-04 claim forms.

TECHNICAL SKILLS:

SDLC Methodologies: Waterfall, Agile (SCRUM, XP), Hybrid (SCRUM-Waterfall)

Operating Systems (OS): Windows XP/8/10/Vista, Linux, Mac OS

Modeling Tools: MS Visio, Mock-up screen, Erwin, Enterprise Architect

Requirement Management Tools: JIRA, Rally

Languages: SQL, HTML, CSS, XML

Reporting Tools: Tableau Desktop, IBM Cognos, ExcelETL Tools: Informatica (Power Center), SQL Server Data Tools, Cognos Data manager

Databases: MySQL, IBM DB2, Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Norfolk, VA

Sr. Business / System Analyst

Responsibilities:

• Worked on implementation of new markets with defining and managing the scope of new systems requirement.
• Responsible for the development and maintaining EDI Data Mapping documents 277, 835, 837.
• Responsibilities include developing and documenting requirements, ensuring all compliance standards are met, coordinating testing, evaluating and identifying possible application system issues
• Create, maintain, and organize backlog of features, epics, stories, and tasks in JIRA.
• Validated Inbound and outbound 837 transactions, including loading and correcting any errors with the process of EDI outbound files.
• Execution of W eekly and M onthly reports and processes and the creation of ad-hoc reports.
• Validated and Created queries for the analysis of data relating to claims, members and providers.
• Involved in Source Data Analysis, analysis and design mappings for data extraction.
• Responsible for maintaining HIPPA validation for 837 outbound files for various markets (Washington DC, Washington State, Kentucky, Virginia Anthem, Virginia CCC+)
• Performed User Acceptance Testing for the ANSI X12 Version 5010 / EDI transactions (HIPAA) for Claims Status and Eligibility (277, 837P, 837I, 837D, 835 remittances and NCPDP Claims).
• Remediated errors received from state for different markets for claims with missing segment elements.
• Performed Data mapping to validate and customize Claims daily load into FACETS for processing the transactions.
• Acting as an intermediary between business and IT in order to link both the views of the system and confirm the solutions provided by the technical side meet the requirements of business.
• Configured HL7 ADT and Scheduling interfaces in Epic Bridges
• Experience includes HL7 mapping documentation, altering interface profile variables in Bridges, monitoring interface errors and meeting with staff to determine interface specifications etc.
• Participated in designing and developing business specifications for HIPAA Compliance for different HIPAA Transactions on Consumer Health Care Claims.
• Conducted focus groups with the SMEs to obtain inputs on their requirements.
• Working on ANSIX12
• Pulling data from FACETS and ODW tables
• Proficient in using Agile Scrum methodologies, working with Scrum Master following sprint/standup sessions and used Excel extensively to write user stories and acceptance criteria.
• Worked with ODBC interface in order to access Database Management systems like Microsoft SQL Server and Microsoft Access
• Conducted Requirements Clarification Sessions with concerned project members to clarify requirements.
• Good interpersonal skills, committed, result oriented and hard working.

Environment: Facets, Jira, MS Sharepoint, MS Visio, SQL, Oracle, MS Access, MS Excel, MS Word, MS Powerpoint, Notepad++, UltraEdit, DBeaver .

Confidential, Jacksonville, MO

Business Analyst

Responsibilities:

• Prepared scope of the project and developed new business process along with process mapping and user task analysis. I also evaluated documentation analysis and business process analysis to identify the problem with existing system and find out new and advance way to develop business process, which was able to make the process more accurate.
• Garnered information and knowledge on ICD 9-10 and HIPAA 4010/5010 as well as Developed the transaction process more accurate and real time regarding 837 including HIPAA Government Regulatory Compliance and also integrated the system with HL7 process.
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Conducted JAD session with business side to identify and gathered high level requirements and evaluated the priority level on the basis of meeting discussions and comments on requirements.
• Developed a vision plan that defined the primary goals and objectives of the project. Analyze user stories and segregated them into high level and low level.
• Utilized corporation developed Agile SDLC methodology used scrum work pro and Microsoft office software to perform required job functions.
• Derive the required data by SQLs and export into Excel files
• Designed and defined User Interface requirements and visual patterns by creating wire frames and screen mockups.
• Strong understanding about user interface (UI) and user experience (UX) design principles and users centered methodology.
• Developed user guides, provides user training, and supports the user in development of work processes. • Supported UAT to evaluate the system performance and also developed system plan to quality center, review design, view test cases.
• Generated reports for quality metrics using SQL Queries.
• Maintained Change and Traceability Matrix throughout the project keeping track of the scope, timelines and budget of the project as well as collaborated with development team to determine the security access and it's tracking to ensure privacy of End users.
• Used SQL for querying underlying database tables.
• Wrote various SQL queries to create, update, modify tables, create reports and retrieve information from the database.
• Creating application specific test plans and test case to support User Acceptance Testing (UAT)
• Provided weekly status updates to project stakeholders on the progress of project development activities.
• Worked with developing team to create advance claim submission process for Medicare and Medicaid patients as well as EDI transaction such as: 837 (P, I, D), 835, and 276/277.

Environment: SQL Server, .NET, Windows XP, Informatica, Facets 4.51/4.71, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, Java, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML.

Confidential, Lincoln, NE

Business Systems Analyst

Responsibilities:

• Worked as a liaison between the business client and development team for the implementation of 4010 to 5010 transition in compliance with HIPAA standards.
• Involved in the HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Identified the business functions and processes, and prepared system scope and objectives based on user needs and industry regulations.
• Defined terms, conducted stakeholder analysis, elicited business needs, conducted business process modeling, and facilitated JAD sessions. Elicited, documented requirements and use cases. Analyzed, validated & prioritized requirements; traced requirements to related project documentation (process models, designs, test scenarios & scripts).
• Documented the Requirements and circulated them to Business & Technical teams for Signoffs.
• Coordinated with the developer and testers for transition of EDI X12 4010 series to 5010 series. Maintained traceability through updates to the Requirement Traceability Matrix (RTM) using Requisite Pro.
• Identified testing scenarios and defined Test Cases for detailed functional testing.
• Involved in forward mapping of ICD 9 to ICD 10 and backward mapping of ICD 10 to ICD 9 using General Equivalence Mappings (GEM).
• Developed a Schedule and identified project milestones.
• Analyzed business scenarios to track possible business outcomes for the functions which could be incorporated into more detailed test scripts.
• Reported project progress to the team, senior management and all stakeholders periodically.
• Identified risk and project impact and performed risk assessment and mitigation.

Environment: SQL, MS Word, Excel, Access, Oracle, DB2, Lotus Notes, File Viewer, Web Client, Clear Quest, Requisite Pro, GEM, MS Visio, SharePoint.

Confidential, Nashville, TN

Business System Analyst

Responsibilities:

• Gathered requirements from stakeholders for provider management and member management.
• Identified and validated business rules and data elements.
• Developed the stakeholder list and created stakeholder assessment matrix to prioritize them.
• Developed and Maintained Requirements work plan and assessed the performance metrics of the team members.
• Created and Analyzed Business Requirement (BR) and Functional Requirement, Directed development team to developed Member login Web Portal (Intranet).
• Worked on Document Management, used Workflows to route documents from person to person so they can complete their document management tasks, such as Reviewing documents, approving their publication and managing their disposition.
• Modeled the ‘as-is’ process flow and the ‘to-be’ process flow and analyzed the gap and developed the action steps to fill the gaps.
• Proposed strategies to implement HIPAA 5010 in the new MMIS system and worked on planning and documentation.
• Worked extensively with ETL process, migrated data from old system to new one, make sure that data format match new system requirement.
• Facilitated JAD sessions for Requirement Validation with Client Dept. of Health & Human Services (DHHS).
• Worked on Electronic Data Interchange (EDI), and Implementation knowledge of HIPAA code sets, ICD-9, ICD-10(Migration, Mapping, Verification of ICD).
• Developed UAT test cases associated with the functional requirements.
• Analyzed Health plan claim processing (ANSI X12 837/835) file and Premium Payment (ANSI X12 820) file specifications under HIPAA framework.
• Prepared implementation plan and negotiated agreement on EDI file specifications with Trading Partners and vendors in accordance with HIPAA guidelines.
• Interfaced with technical staff, trading partners, Clearinghouses and internal staff including programmers on all HIPAA related information and changes.
• Teamed up with Senior Management, Legal to formulate EDI Trading Partner Agreements in accordance with HIPAA compliancy rules.
• Wrote companion guides for several EDI formats evaluating system requirements and business rules.
• Analyzed different Data cross-walks, complicated logic & look ups required by different fields for the source to target transformations.
• Broke down the services from the HCA MMIS Logical Design into multiple layers of normalized functionality that correspond to utility services, general business services and Medicaid specific services.
• Participated in developing Team Foundation Server (TFS) test plan, test scripts, and test scenarios and designed user documentation.
• Worked with legacy team in developing BRD for multiple system change requests and participated in System Testing.

Environment: MS Office, Windows 2000, .NET, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Oracle, SOA, HTML, FMS/3

Confidential, Durham, NC

Business Systems Analyst

Responsibilities:

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements.
• Designed a claim processing system for the healthcare management client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms (ICD codes), and treatment (CPT).
• Responsible for gathering the functional requirements for the health benefit claims receiving and processing system.
• Conducted requirement gathering sessions with the purpose of creating and defining the Business Requirement Document (BRD) and the Functional Requirement Document (FRD) using Rational Requisite Pro.
• Involved in Requirement Scoping and analyzing high priority requirement. Conducted sign-off meetings with IT teams to lock down the requirements.
• Created high-level Use Cases from Business Requirements and created UML diagrams like Use Case and Activity diagrams using MS-Visio.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives with each other, resolve any issues and come to an agreement quickly.
• Tracked stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Involved with the following list of HIPPA-EDI Transaction Code sets: 837, 835, 270/271,277/275 and 276/277
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Involved with the Quality Assurance Team to develop and design test plan and test cases.
• Executed test cases and test scripts for manual and automation testing. Defects are raised in the HP Quality Center/HP ALM for logging, tracking and reporting bugs in the application.
• Conducted User Acceptance Testing (UAT) of the application with the QA team.
• Performed testing of the health benefit claims receiving and processing system to ensure that the system adheres to project standards, performance criteria, and functional specifications.

Environment: MS Office Tools, Windows XP, Facets, MS Project, SharePoint 2007, MS-PowerPoint, SQL, Agile framework

Confidential, Columbus, OH

Business Analyst

Responsibilities:

• Coordinated JAD sessions to understand the user requirements and also their system's implementation.
• Used both Agile/Scrum methodology for the web application used by Agents and Underwriters for providing new sale Insurance plans and Renewals of a group/company.
• Was Able to understand business goals and business context and translated them into technical specifications
• Demonstrated experience defining impacts of conversions, business rules, and configuration decisions on downstream systems and interfaces.
• Worked in Service Now incident management system as a member of production support team.
• Managed a team of offshore developers in Europe and a team of offshore testersin South Asia.
• Experienced in web services concepts and support utilities, related database utilities. Demonstrated understanding and experience with ETL, Stored Procedures, and Queries.
• Involved in gathering requirements, identifying and preparing Use Case specification documents, creating Trace-ability matrix and tagging it in the Rational Requisite Pro.
• Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagrams using Rational rose so that developers and other stakeholders can understand the business process.
• Identified and documented issues, risk and gaps, their descriptions, their impact and provided recommendation and alternatives to develop the application to meet the user requirements.
• Exposure to Rational Clear Quest to track Project status, monitor workload and detect issues including defect submissions and enhancement requests.
• Synchronized and prioritized relevant defects and enhancement/system requests based on business requirements, allowing sufficient time frame to ensure accuracy and consider deadlines.
• Wrote standard and complex SQL queries using MS SQL Server and also in Mainframe for data validation process.
• Wrote requirements for various reports to be generated and migrated.
• Maintain documentation related to difficulties, complexities and anomalies that may arise during the ETL process.
• Regularly followed up with Development Team to discuss discrepancies identified during testing and act as a liaison between Project Manager and SME and development and testing team.
• Served as a liaison between the users, facilitators and the project team as a team lead.
• Involved in the development of Project Plan in conjunction with the Business and IT areas.
• Participated in User Acceptance Testing and Business-to-Business Transaction testing for the project.
• Supported for the creation of test plans and the debugging of problems.

Environment: AS400, Service Now, Rational Rose, Rational Requisite Pro, Show Case SQL Query, UML, HP ALM, Java, MS Project, MS Office, MS SQL Server, Windows XP, Squish, Lean Six Sigma.