SUMMARY:

• Over 7 years of experience as Business Analyst in the Healthcare Industry with expertise in Affordable Care Act (ACA), HL - 7, EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare and Medicaid.
• Business Analyst with solid understanding of Business Requirements Gathering, Business Process Flow and Business Process Modelling and Data Mapping.
• Experienced in business process flows, business process modelling, case tools, business analysis, gap analysis and organizational change management, experienced in conducting sessions and worked with executives, developers, and end-users to define the exact requirements.
• Extensive working experience on Medicaid, Medicare and MMIS projects. Solid understanding of Membership, Claims Processing, Billing, Benefit/ Eligibility, Authorization/ Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions (837, 834 and 820).
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS.
• Knowledge on Medicare, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.
• Used Microsoft SharePoint as a Web-based Content Management System as well as a Document/ Project Management tool.
• Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment).
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Medicare, Medicaid, CDHP (consumer driven health plans).
• Ability to develop business rules, context data flow diagram, entity relationship diagram, workflow diagramming, prototyping and document current state, gaps and future state processes.
• Experience in multi-tasking such as managing numerous simultaneous projects with great attention to detail.
• Experience in solution assessment, validation and applying critical thinking for problem solving approach.
• Experience in Requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.
• Comprehensive knowledge of Software Development methodologies (SDLC) such as Waterfall, Agile, Spiral and Scrum.
• Create various documents like the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS).
• Good Knowledge of software and applications designing tools for the preview of the project at the very beginning.
• Worked closely with project Stakeholders, SMEs, PM, to understand, analyse, document, validate, and review the requirements and specifications for new applications along with enhancements to the existing applications.
• Efficient in writing Business Requirement Document (BRD), Functional Specification Document (FSD), Use Cases, User Interface Specifications (UIS), System Requirement Specification (SRS) and Report Specifications Documents.
• Skilled in translating business requirements and user expectations into detailed specifications and building business process flow charts using MS Visio and Enterprise Architect to communicate project functionality to the development team employing designing techniques like OOAD and Unified Modelling Language (UML).
• Sound proficiency in analysing and creating, Use Case Diagrams, Sequence Diagram, Activity Diagram, Data Flow Diagrams, Business Flow Diagrams, Wire Frames and Mock-ups using MS Visio and Rational Rose to communicate business and functional requirements to clients and developers.
• Performed AS-IS and TO-BE business process flow for clear translation of Functional to system requirement specification.
• Support the Test Team and the rest of the Development Team in compliance related issues while working with them in the development phases of the projects.

PROFESSIONAL EXPERIENCE:

Confidential, La Jolla, CA

Healthcare Business Analyst

• Develop business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
• Manage company's EDI catalog for prospective EDI customers.
• Involved in HIPAA 5010 gap analysis of ANSI X12 4010 and ICD 10 initiatives.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Implement new services and programs via MMIS for the Medicaid program by directly interfacing with the customer and the system engineers on a regular basis.
• Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for both HL7 ADT interface and the application.
• Developed a work plan that ensured RFP would meet federal prior approval requirements including use of modular project development, compliance with MECT, MITA, HIPAA and other federal guidelines
• Creating documentation such as BRDs and FSDs (Business and Functional design specs) with elaborate Use Cases and process flows
• Worked on FACET claim processing system and gathered and documented functional requirements in the Functional Requirements Document (FRD).
• Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
• Analyze and document Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
• Prepared Business Requirements Documents, Functional Requirement Documents.
• Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA 5010 requirements.
• Facilitated all Aspects of scrum framework, including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and sprint retrospectives.
• Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.
• Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.
• Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.

Confidential,Buffalo, NY

Healthcare IT Business Analyst

• Acted as a liaison between Business and IT throughout all phases of SDLC.
• Facilitated JAD sessions with all the important stakeholders for gathering requirements.
• Gathered requirements through one on one meetings with business owners.
• Documented all the requirements in blueprint.
• Created documents like Requirements Specifications Document, Correspondence Requirements Document, Data mapping document etc.
• Peer Review of the documents with the fellow business analysts before handing off to the Solution Architects or the developers.
• Sign Off from the business for the documented BRD's and CRD's.
• Uploaded the documents to the project SharePoint site for maintaining records, for future changes and for easy traceability for the team members.
• Acted as a liaison between Business and IT throughout all phases of SDLC.
• Facilitated JAD sessions with all the important stakeholders for gathering requirements.
• Gathered requirements through one on one meetings with business owners.
• Documented all the requirements in blueprint.
• Created Correspondence Requirements Document (CRD), Correspondence Mock ups, Fulfillment Data mapping documents etc. required for the correspondence.
• Peer Review of the documents with the fellow business analysts before handing off to the Solution Architects for Arch review.
• Sign Off from the business for the documented CRD's.
• Uploading the documents to the ECM SharePoint site for maintaining records, for future changes and for easy traceability for the team members.

Environment: Agile, Blueprint, Outlook, MS Word, MS PowerPoint, MS Excel, MS Visio, SharePoint, Notepad, OneNote.

Confidential,Butner,NC

Healthcare Business Analyst

• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle which involved gathering, analysis and documenting business and technical requirements from both formal and informal sessions
• Created Use Cases and Business Requirement Document after accessing the status and scope of the project and understanding the business processes.
• Performed Feasibility Study and Risk Analysis to identify the critical requirements from the user's perspective.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules.
• Gathered requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act (PPACA)
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Validated 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response) and 834 (Enrolment/Dis-enrolment to a health plan)
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, Claims Processing, Insurance Pricing and Claim Adjudication.
• Mentored business analysts in methodology for defining ICD-10 mapping processes and documenting business requirements
• Interacted with Claims, Payments and Enrolment hence analysing and documenting related business processes
• Worked with the SMEs (Subject Matter Experts), IT managers, software architects to identify the key changes pertaining to HIPAA, and participated in Health Management to communicate effectively with them.
• Performed Requirement Analysis, Impact Analysis and documented the requirements using Rational Requisite Pro.
• Assisted in Change Management and Release Management by requesting, implementing and evaluating changes to the system using Rational Requisite Pro and recording defects using Quality Center.
• Reviewed the Joint Requirement Documents (JRD) with the cross functional team to analyse the High-Level Requirements • Designed and managed Oracle database having functions, procedures, views, indexes and triggers using Toad. • Extensively used Toad for SQL scripts and worked on SQL for enhancing the performance of the conversion mapping. • Develop test data and execute test plans while defining and/or modifying testing procedures. • Extensively used SQL in Oracle Toad to join the tables, to fetch data and for Data profiling/Data Mining • Performed data analysis by using SQL queries and used Query Analyzer optimize SQL Queries • Performed Unit Testing and User Acceptance testing (UAT) assisted in developing Test Plan and Test Cases to be used in testing based on Use Cases and Functional Specifications.