SUMMARY:

• Experienced and distinguished Business Analyst with Six years of experience in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with zenith focus on claims adjudication, eligibility, provider and prior authorization for Medicaid and Medicare programs.
• Extensive experience in the development, implementation and integration strategies towards a team oriented environment, utilizing quantitative and qualitative analytical skills.
• Great command in communicating/converting clients vague/non-technical requirements into precise/concise representation to the team.
• Experience in developing detailed functional specs through JAD sessions, interviews, on site meetings with business users & development team.
• Documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document) and Non-functional Requirement Document.
• Experience in interviewing Business users & SMEs providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• In depth knowledge in Test Case writing (manual/automated test cases) and Conducting Tests (Integration testing, Regression testing), Black Box/White Box testing, UAT (User Acceptance Testing). Extensive knowledge of Analysis & Design (Use Case, Sequence and Activity diagrams).
• Writing Manuals (System guides, training material for business users and Deployment guides).
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users
• Good knowledge and extensively used RDBMS, Oracle, SQL, PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile& Waterfall life cycle
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with data analysis, data mapping and dimensional modeling experience in decision support systems (data marts) using Star Schema.
• Strong understanding of FACETS and Facets Data Model working on data model and data extracts.
• Experienced working in Facets online modules such as Billing, Provider, Claims and Membership modules.
• Strong knowledge of Facets interaction with various input systems like Rate Manager, Ingenix Winstrat/webstrat, PBX, CCA, NetworkX and the rules defining the behavior of Facets.
• Work experience in data warehousing projects dealing with ETL (extraction, transformation, load) using Oracle
• Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Experience with HIPAA compliance (4010 & 5010) and Healthcare systems
• Experience with Medicare, Medicaid, Medigap/Medsupp & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9, ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Experience with health care Systems: FACETS, QNXT, Medicare Part A, B, C, D, Medicaid and BDS (Business Distributor System).

TECHNICAL SKILLS:

Methodologies: SDLC, RUP, UM, Agile
Project Management: Microsoft Project, Microsoft Office
Modeling Tools: Rational Rose, Microsoft Visio
Change Management Tools: Rational Requisite Pro, Clear Quest, Test Director.
Version Control Systems: Rational Clear Case
Testing Tools: Rational Enterprise Suite, Test director, Win Runner
Languages: C, C++, Java, .Net, XML, UML, HTML
Databases: Oracle, MS SQL server, MS-Access
Operating Systems: Windows family, familiar with UNIX and LINUX
RDBMS and Databases: SQL Server, Sybase MS Access Reporting Tool: Business Objects

EDUCATION:

Bachelors in Accounting

PROFESSIONAL EXPERIENCE:

Confidential, Cerritos, California Dec 2011- present
CareMore is a senior based health care company in the southwest serving Medicare population around California, Nevada and Arizona. Recent acquisition by WellPoint has opened new horizon for CareMore as they will be acquiring new markets and more members and providers from newer zones. This company serves reputation in helping seniors lead a healthy and prosperous life while taking care of their medical situations.

Environment: MS Share point, VSS, Footprints, Facets 4.71, MS Office, MS- Visio, AE, SQL

Project description:
Implementation of BDS (Business Distributor System) from WellPoint.

Roles and responsibilities

• Preparing Business and functional requirement documents to access all the requirements for the successful implementation of the BDS.
• Used Agile methodology to develop process and standards.
• Created work flow diagrams, activity diagrams and use case diagrams to represent the relation between the business and users.
• Developed a logical Integration model detailing the flow of information through the various components, including definition of external and internal message contents.
• Conducted JAD sessions with various SMEs and users to analyze and discuss project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Developed data mapping documents to support the data extracts to be supplied to BDS for identification of the claims.
• Developed data mapping document to prepare a proprietary file with details of claims that are received.
• Assisted in preparing the architectural design for the implementation of the BDS.
• Supported the Program Manager in balancing project goals and business needs.
• Developed test scripts and test cases to test the eligibility as well as claim side of the BDS implementation.
• Performed unit testing on various members to test the daily difference logic that was prepared to support the daily data pull from facets to BDS.
• Created TPA for Anthem within the THG using TPM to satisfy the testing of claims that are received from Wellpoint via BDS.
• Tested claims to be recognized, processed and properly adjudicated by THG and Facets.
• Attended daily SCRUM and guided IT Developer regarding the defects.

Confidential, Seattle, Washington, June 2011 – Dec 2011
Position: Business Analyst
Premera blue cross is a leading healthcare company in the northwest and it serves greater northwestern area of Washington, Oregon and Alaska. This is one of the components of Blue Cross and Blue Shield chain of businesses. It offers claims processing, solutions development for the healthcare industry. This company looks over the health plans of PBC (Premera Blue Cross), Life Wise and PBCBS (Premera Blue Cross and Blue Shield of Alaska)

Environment: Ms Share point, TFS, Facets 4.71, CCA, MS Visio, MS Office, SQL, CVT
Project description:
Developing a new care management program called disease management to support healthy living
Impact analysis and remediation of ICD- 9 to ICD-10
Roles and responsibilities:

• Preparing Business and functional requirement documents to access all the needs of the Disease Management program and the software and solutions that are going to be used by this new program.
• Used Agile methodology to develop process and standards.
• Created work flow diagrams, activity diagrams and use case diagrams to represent the relation between the business and users.
• Developed a logical Integration model detailing the flow of information through the various components, including definition of external and internal message contents.
• Conducted JAD sessions with various SMEs and users to analyze and discuss project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts
• Prepared test scripts for the successful execution and testing of Inbound IVR, Vendor supported outbound IVR and CCA Care Bridge.
• Performed testing on the Inbound IVR, CCA and reports parts of CCA and logged defects into the DM Sharepoint and assigned the defects to the designated personnel.
• Created a dummy data pull in the Facets 4.71 for testing of Disease Management Program.
• Worked on business requirement documents and use cases on weekly EOB file sent to AIM an external vendor to ensure the compliance to the corporate policies.
• Accessed and analyzed several systems within Premera’s system for remediation of ICD-9 CM to ICD 10 CM/PCS. Prepared functional requirement documents to document the change necessary to be federally complaint.
• Did data analysis and created data mapping and data analysis document.
• Analyzed ICD 9 Procedure and Diagnosis Codesin accordance withICD 10 CM and ICD 10 PCS Conversion Compliances for various systems that are used within Premera.
• Worked with OptumInsight for successful installation of Winstrat v1108.
• Worked on maintenance of Facets 4.71 by testing and implementing Facets patches as per the COSMOS tickets that are loaded in TFS.
• Supported the Program Manager in balancing project goals and business needs.
• Attended daily SCRUM and guided QA and IT Developer regarding the defects.
• Worked on EDI transactions 834,837 and 835.

Confidential, Tampa, FL January 2010– June 2011
Position: Business Analyst
Infocrossing Healthcare Services, Inc. provides information technology outsourcing and transaction management solutions to the healthcare industry. It offers claims processing, business and clinical application hosting, health plan application, and information technology infrastructure services for the payer, provider, and government markets.
Environment: IDX, MS Visio, MS Office, Rational Rose, Requisite Pro, SQL, Oracle, FACETS.
Project description:
Up-gradation of HIPAA 4010 to 5010 and ICD 9 to ICD 10
Up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously
Roles and Responsibilities:

• Ensuring that X12 transactions can be carried out as per the EDI standards during any of the system changes as well as system upgrades.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Utilized Agile Methodology to configure and develop process, standards and procedures
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts
• Created workflow diagrams, UML diagrams, activity diagrams, use cases for incorporating design changes in the order creation/ management system
• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Did data analysis, created data mapping and data interface documents and kept the documents updated with changes in requirements and functional specifications.
• Worked on developing the business requirements and use cases for FACETS batch processes; automating the billing entity and commission process
• Involved in claim adjudication process of FACETS application
• Worked on the EDI 834-file load to Facets through MMS (Membership Maintenance Sub-system).
• Created 3500, 5000 byte files for different regional data-warehouses.
• Wrote requirements to develop Web basedReporting toolwhich will be capable to generaterecurring reports, Ad-hoc reports,andtrack reports.
• Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems as well as for ICD 9 to ICD 10
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEM
• Ran SQL queries to analyze the requirements and for testing the files and reports.
• Created 3500, 5000 byte files for different regional data-warehouses. Involved in creating FTP process for data exchange between database and adjudication systems. Actively participated on creating Migration strategy from existingPDE(Microsoft Access files) toGold Data Repository.

Confidential, Nashville, TN February2008 to November 2009
Position: Business Analyst
Environment: MS Visio, MS Office, Rational Rose, Requisite Pro, SQL, Oracle, FACETS, NextGen 5.5
Project description:"The Goal of this project was to design, create and implement a flexible, and intuitive expense reporting system that gives the flexibility and ability to accurately and efficiently account for all levels of travel and expense spend including spend onHealth Care Professionals (HCPS) .I was responsible for the development, maintenance and implementing Electronic Health Records (EHR) system utilizing NextGen 5.5. As IT Team Lead at the clinic, I supervised the other IT staff and all EMR related issues are escalated to me."
Roles and Responsibilities

• Gathered requirements for new templates from doctors and nurses through interviews.
• Used NextGen 5.5 Electronic Medical Records to create templates and documents for EMR.
• Tested new templates and documents for bugs. Tested Extracts and files before and after theETLProcess. Wrote script for various reports.
• Wrote requirements to develop Web basedReporting toolwhich will be capable to generaterecurring reports, Ad-hoc reports,andtrack reports.
• Responsible for the creation and implementation of businessrequirements and data dictionaries for compliance with CHI Initiatives.
• Utilized effective communication skills by serving as the main point of contact between end users, vendors and in-house developers.
• Worked on XML tools with various documents for further processing and worked on XML API\'s.
• Tested all the features of the EMR after every upgrade of NextGen. Created error categories: based onerror codes, correction type, necessary intervention type, etc.
• Installed ePad for Electronic Signature of documents and Dragon Naturally Speaking for transcription.
• Delegated tasks to other developers and signed off on their work upon satisfactory completion.
• Developed teamwork ability by working in a team of 5 developers and created businessprocesses flows and process maps
• Conducted Functional and Design Testing for NextGen.
• Responsible for updating and troubleshooting office computer equipment on Java.
• Recently began to use Crystal Reports to create reports based on treatment outcomes.
• Worked on EDI transactions 270 (eligibility request), 271(eligibility response), 276(status request), 277(status response), 837(claim process), 835(claim remittance), 834(health plan enrollment.)
• Coordinated and attended meetings to review the requirement specifications with the Quality Assurance Manager and other team members.
• Working knowledge in ICD 9/ANSI Health codes/HL7/ADT in the claims environment for inpatients and outpatients; reviewed the implementation of the changes made in the systems as per the formats and compliance for EDI usage. Also dealt with different EDI transactions like 834, 835 and 837 specializing in claim processing.
• Performed Analysis ofICD 9 Procedure and Diagnosis Codesin accordance withICD 10 CM and ICD 10 PCS Conversion Compliances.
• Involved in electronic health data management including data interchange to standard ICD9, CPT form
• Evaluated application testing results against ANSI standards and recorded the discrepancies using Test Director to track, analyze and report on them and ran SQL Queries for reporting purposes.

Confidential, Franklin Lakes, NJ January 2006 to January 2008
Position: BusinessAnalyst
Environment: Windows, Rational Unified Process (RUP), CMMI, Six Sigma, UML, MS Office Tools – MS Word, MS Excel, MS Access, MS Visio, MS PowerPoint, Brio Query, Requisite Pro, Clear Quest.

Description:
(Medco Finance Medicare Part D Transition Project):
Medco Health Solutions, Inc. is the nation\'s leading PBM with different prescription drug benefit programs that are designed to drive down the cost of pharmacy health care for private and public employers, health plans, labor unions and government agencies of all sizes, and for individuals served by the Med D Prescription Drug Program.
In Medco Health, I worked for Medco Medicare Part D Finance team which comprised of Premium Billing, Insurance Accounting, Accounts Receivable as well as Medco Finance IT team. I worked as aBusinessAnalystin the Transition to TMG Health project to implement Trizetto\'s FACETS application to perform all the financial operations & activities.
Roles & Responsibilities:

• As a business analyst in Medco Finance team I worked in the SDLC, starting from Inception to transition phase in (Rational Unified Process) RUP. I also worked on Use cases, Vendor Requirement Specifications, Architectural Documents, System flow and work flow diagrams. My responsibilities included understanding, articulating, extracting and refining User requirements by conducting JAD session, facilitating meetings and interview with business users and technical support teams and the (Subject Matter Experts) SMEs.
• Designed and developed numerous documentations based on model & Six Sigma standard. Created numerousCapability Maturity Model Integration (CMMI) BusinessRequirement documents and converted those into use cases, functional & system requirement specifications so that developers can understand thebusinessprocess and rules according to their perspective.
• Defined and developed requirements for banking pre-registration file, remittance file, lockbox, credit card & ACH/EFT processes, cash reconciliation, delinquency letters and invoice samples.
• Created different Standard Operating Procedures (SOPs), policies and workflows.
• Analyzed and developedbusinessand functional requirements for the Financial Client Reporting website and including Med D Banking Payment Option for the members & Clients in the Medco Home Page.
• Performed the Data Analysis for Data staging & Teradata Database design for the To-Be reporting system. Created data mapping specs for IBM Mainframe system, Teradata and Data warehouseto target system, share drive, access database and application.
• Created database design and data mapping documents for CMS historical data. Employed UML methodology to develop the business architecture, data flow models, and different solution options in use case diagrams, flow diagrams to assist development team to understand the requirement.
• Designed Requirements Traceability Matrix (RTM) to trace the relationship between business and functional requirements to test cases and achievement metrics on an ongoing basis for keeping the team informed of the progress of the project.
• Validated technical design documents created by IT developers against functional specifications.
• Assisted End User in performing User Acceptance Testing and tested the end results files created by the development team to verify whether all the requirements were accessed.
• Created numerous Test Cases, Test Conditions and Test Scenarios for Premium Billing, Accounts Receivable, & Insurance Accounting sub-teams to be used as testing base for assists Testing QA team to performs End to End with the transitioning vendor and ultimately to Facets application.
• Defect tracking and prioritizing defects after base lining the requirements by facilitating Proof of Concept sessions.