SUMMARY:

• Over 6 years of experience as a Business Analyst/ Business System Analyst in Health Care domain.
• Experience in working with various Software Development Life Cycle (SDLC) methodologies such as Waterfall, Agile specifically Scrum.
• Created numerous artifacts such as Business required Document (BRD), Functional Required Document (FRD), Requirement Traceability Matrix (RTM).
• Experience in all phases of the SDLC, including requirements gathering, design phase, build, testing, and production deployment and Maintenance &support.
• Experience in Scrum practices like User stories, Backlog Grooming, Release Planning, Sprint Planning, Sprint review and Sprint Retrospective.
• Experience in working with various Health Care systems such as Enrollment system, Membership system, Provider Enrollment system, Provider Information system, in Claims Adjudication, Membership Administration System, Benefit Administration System.
• Developing new or modified existing SAS programs to load data from the server and run into a scheduler.
• Extensive knowledge about the various types of health insurance plan such as Medicaid, Medicare (Part A, B, C and D), PPO (Preferred provider organization), HMO (Health maintenance organization).
• Experience with various FACETS modules such as Subscriber/Member, Claims, Plan/ Product.
• Experience working with TriZetto FACETS for implementation and Claim & Benefit configuration.
• Immense knowledge on Explanation of Payment (EOP), Explanation of Benefits (EOB), Co - ordination of benefits (COB), Structure, format and standard of Electronic Data Interchange (EDI).
• Experience in working with ICD 9 to ICD 10 conversion and immense knowledge on 4010 to 5010 conversion.
• Experienced in gathering requirements according to HIPPA (Health Insurance Portability and Accountability Act) EDI (Electronic Data Interchange) Transactions EDI 820, EDI 834, EDI 835, EDI 837 (I, P and D), EDI 270, EDI 271, EDI 275, EDI 276, EDI 277, and EDI 278 in various phases of implementation.
• In Depth understanding of the AS-IS and TO-BE business processes and experience in converting these requirements into technical specifications for preparing test plans.
• Experience in utilizing MS Access to build a database for a small and complex business application and upgraded/migrated numerous processes being tracked using Excel to more functional, user friendly and reliable MS Access applications.
• Experience with various database management systems such as DBMS (Database management system) and RDBMS (Relational Database management system).
• Knowledge on Affordable Care Act (ACA).
• Exceptional skills for writing Use Cases and Functional Requirement Documents as well as for creating Use Case diagrams, Activity diagrams, based on UML Methodology and business process flow diagrams using MS Visio.
• Experience in ETL process (Extract, Transform and Load).
• Proficient in writing the Standard Query Language (SQL) queries and SAS.
• Extensively used tools such as JIRA, HP QC/ALM, Rational Requisite Pro, Rational Rose, Clear Quest, MS Visio, MS Office, MS Access, MySQL.

TECHNICAL SKILLS:

Requirements Management: Enterprise Architect, HP Quality CenterUML Diagrams: MS Visio, Enterprise Architect

Wireframes& Screen Design: MS Visio, Azure RP

Test Cases: HP Quality Center/ALM

Defect Tracking: HP Quality Center/ALM, JIRA

Software Methodology: Agile, Waterfall

Microsoft Tools: MS Word, Advanced MS Excel, MS Power point

Databases: MS SQL, DB2, MS Access

PROFESSIONAL EXPERIENCE:

Confidential, Dayton, OH

Business System Analyst

Responsibilities:

• Involved in gathering and creating functional and non-functional requirement documents, Use Cases, Wire Frames, end to end system work flows, interface diagrams, mapping documents, presentations, message specifications, test scripts for enrolling and maintaining groups and individuals.
• Created architecture Solution flows, UML diagrams, service charters and detailed message specifications for development of messages/interfaces which using Business Process Modeling Notations (BPMN).
• Created Requirements Traceability Matrix and support in creation of enterprise solution architecture to integrate business rules across domains.
• Cleansing and validating complex data using data step, proc steps and SAS functions.
• Participated in UAT along with the development & testing teams.
• Load data using ETL process dealing with different data sources (MS Excel, MS Access and SQL Server, Flat Files etc.) into target database by performing different kinds of transformations using SQL Server Agent to automate the SSIS package execution.
• Created and maintained documentation related to the project including scope document, vision document, functional specification document, defect status report, mitigation plans, supplementary requirements specification document and impact analysis document.
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Extensively worked on preparing the test plan for EDI transaction like 834, 835, 270/271, 276/277, 278.
• Worked on different EDI transactions like 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270/271 for Eligibility inquiry, and 276/277 for claims status.
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Conducted process mapping to identify current As-Is business processes and To-Be road map for reengineering the products.
• Used SAS Macros, PROC SQL to extract, sort, match test accounts and ODS to HTML, PDF and RTF.
• Performed Database testing using DB2 Connect and Extra tools for verification of data tables in database.
• Created mapping documents for 837 Institutional, Professional and Dental claims.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Extensively created Business Process Modeling Diagrams/Swim Lane Flows using BPMN notations and MS Visio indicating transformations and feeds.
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.).
• Conducted UAT. Wrote SQL queries in MS Access and Oracle for data manipulations.
• Created crosswalks to support list of values across enterprise for reusability and for supporting CDM.
• Performed extensive GAP analysis and created Message Specification Documents for service calls.

Environment: Windows, MS Office (Excel), SAS, MS Visio, SharePoint, WebLogic Server HIPAA, SQL, BPMN, SSIS, UNIX/LINUX.

Confidential, Bloomfield, CT

Business System Analyst

Responsibilities:

• Responsible for the requirement-gathering phase and project plan.
• Worked on Business Requirement and functional requirement that were implemented and analysis through JAD session.
• Worked with Developer teams to verify the Business requirement document and Vendor logic.
• Worked on detailed plans involving the update and conversion to various internal tables, extensions, back end technical considerations and internal and external interfaces.
• Worked on Configuration Management, Requirement management and analysis.
• Used Migration tools as well as UI bypass in Toad and MS-SQL to perform the migration of the Fee Schedules.
• Checked the documentation in Gatekeeper and approve it for the migration in the FACETS system.
• Used tables, formulas and relational tools to show the relation between the tables in Excel for the upload purposes.
• Created SQL queries to read data from databases.
• Successfully used Agile/Scrum Method for gathering requirements and facilitated user stores workshop.
• Performed IT BA testing for various types of Provider Data and SSRS reports for Medicare Blue/Green Market in Provider Tables of FACETS via MS SQL server.
• Involve in verifying Inclusion Report, Exclusion Report, and Health Plan files using advance MS SQL joins in FACETS Tables and Data Mart.
• Developing/revamping of SAS codes to standardize the process and to improve quality and productivity.
• Involved in the peer review of Test Plans, Test Cases with the BA/QA team to verify implementation of new features and enhancements on Dev, QA, and Production Environments.
• Used TriZetto HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Responsible for monitoring and validating data from SSRS reports and SQL Server data warehouse and FACETS Application.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Used HIPAA transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and involved in designing future state processes for HIPAA transaction processing EDI’s 837, 835, and 834.
• Analyzed HIPAA related to 837,835, 834.
• Worked in testing the professional, institutional claims processing and adjudication and validate data with FACETS.
• Automating the processes using various tools like Excel, VBA and SAS
• Used Requisite Pro for writing/analyzing project vision, goals, specifications and requirements.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in Rational Rose for the Business Use Case and System Use Case.
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.).
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Worked with a QA lead in validating Test Plan and Test Scenarios.
• Experience in relational databases (RDBMS) like Oracle, SQL, and MS Access.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release

Environment: Agile, JIRA, Windows, Microsoft Office SharePoint, SAS, MS Office, MS Access, SQL Server, FACETS.

Confidential, Louisville, KY

Business Analyst

Responsibilities:

• Ensured all artifacts complied with HIPAA 5010 policies and guidelines.
• Formulated and defined systems scope and objectives through research, data mining, analytics and fact-finding.
• GAP Analysis: Analyzed the client's applications programs to determine the impact of the HIPAA final rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance.
• Created ETL documentation such as EDI X12 837(P, I), 834 and 835 Data Mapping, Transformation logic for Main Frame Layout, Updating Meta data documents for new Platform.
• Systems Documentation included Business Requirements Document (BRD), Systems Requirement Specification (SRS) and test plans using Requisite Pro.
• Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Worked on project migration of all Healthcare Process (such as EAB, Products, Provider, Claims, Capitation, Voucher, finance etc) for Dental HMO from Legacy system (AREV) to Facets.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 835, 837 (I, P, D) and 820) standards
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Using SAS to extract transform & load source data from transaction systems
• Captured EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Involved in writing complex SQL queries to check the data integrity.
• Worked with Facets team for HIPAA Claims validation and verification process (Pre-Adjudication).
• Analyzing User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Used MS Access, MS Excel (Pivot tables), SQL to design and test. Used Unix commands for interrogating the files.
• Created tools using MS Access to track financial reporting, automate updating of floorplan, collect forecast data from project managers.
• Performed extensive data modeling to differentiate between the OLTP (Online Transaction Processing) and Data Warehouse data models.
• Upgraded and migrated numerous processes being tracked using Excel to more functional, user friendly and reliable MS Access applications.
• Worked on Facets Claims Processing for data validation and claims validation. Extensively worked on Claims Inquiry and Dental Claims Processing.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Analyzed EDI transactions in XML and X12 responses.

Environment: HIPAA, SAS, MS Excel, Web Logic Server, SQL, Share point, Toad, Word, Excel, UNIX/LINUX.

Confidential, Hartford, CT

Business Analyst

Responsibilities:

• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Involved in documenting the business process by identifying the requirements and also involved in finding the system requirements.
• Validated the EDI 837-claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Validated sql programs using various sophisticated techniques and communicated findings to the concerned.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA (5010)/ EDI formats and accredited standards like ANSI.
• Developed Schemas of EDI ANSI X12 Claims (837) and Eligibility forms in XML.
• Involved in 835/837(P/I/D)/834 (ANSI X12) transaction with implementation guides.
• Involved in claim adjudication process of facets application
• Involved in the complete business process redesign and reengineering effort in converting existing process into a strategic web based environment.
• Used advanced techniques to reduce the execution of process times in SAS.
• Reviewed and gathered requirements from the Subject Matter Experts (SME) and Business Partners using various elicitation techniques and create Scope Management Documents.
• Analysis and Design of the Erisco FACETS data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Created Technical Specifications for the 835 and 837 I and P files with their changed and new contents to create 5010 complaint files.
• Worked with relational databases, and developed PL/SQL queries to interact with Databases.
• Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions include 837, 835, 276, 277, 270 271 - (both inbound and outbound) transactions.

Environment: SQL Advantage, MS Visio, SAS, MS Word, JIRA, Windows, Microsoft Office SharePoint.

Confidential, Boston, MA

Jr. Business Analyst

Responsibilities:

• Gathered Business Requirements, interacted with the Users, Designers and Developers, Project Manager and QA Team to get a better understanding of the Business Processes.
• Followed a structured approach to organize requirements into logical groupings such as requirements for Customer, Client, Group, Member and Reporting that critical requirements are not missed.
• Involved in creating Business Process Documentation. Identified Use Cases from the requirements. Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams using MS-Visio.
• Analyzed the process, Prepared BRD Document and managed requirements using Rational Requisite pro.
• Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions.
• Worked on customization reports related to enrollments and providers in FACETS.
• Creating and Updating Facets security profiles as per the template provided by the clients.
• Conducted Claims and HIPAA Compliance Training to run the test cases. Also worked with NPI.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter, to meet and exceed HIPAA requirements set forth by the federal government.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams using UML.
• Managed RTM (Requirement Traceability Matrix) to track the project flow.
• Prepared BRD and Derived Functional Requirement Specifications (FRS) based on User Requirement specifications and delivered to the project team.
• Identifying and understanding the business critical areas from the user perspective.
• Managed change of the requirements and associated requirements to other requirements for traceability.
• Involved in drawing process flow diagrams using MS Visio for the Claim Adjudication module.

Environment: MS Office, MS Visio, UML, Rational Clear Quest, Adobe Acrobat, PL-SQL, Oracle, SDLC, SharePoint.