PROFESSIONAL SUMMARY:

• Almost 7+ years of diverse experience in the Software Requirements Engineering Process as a EDI Analyst/ Business System Analyst in developing and implementing innovative business processes..
• Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
• Experience in Life Science, Health Care and Insurance industries with solid understanding of Business Process Flows, Case Tools, and Business Analysis
• Specialized in creating UML Diagrams like Use Case, Activity and data flow diagrams using Rational Rose and MS - Visio and consistently translate business requirement into IT solutions.
• Extensive knowledge of reporting tools such as SQL and ACCESS for underlying database tables and resolve data issues.
• Expertise in RDBMS concepts and running SQL queries.
• Clear understanding of ICD-9-CM and ICD-10-CM/PCS
• Well versed with ANSI X12, HIPAA and HL7 standards.
• Experience in working on projects for creating solutions with MS Dynamics.
• Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• Extensive experience in conducting Market Research, Feasibility Studies, Data Analyses, Data Mapping, Data Profiling, Gap Analyses, Risk Identification, Risk Assessment, Risks Analyses, and Risk management.
• Knowledge on HIPAA and HEDIS rules and regulations.
• Experienced in field mapping across all the modules from Legacy systems to JDE tables.
• Experience in managing all phases of life cycle to implement Meditech and related application systems and technologies.
• Exposed to SOX, HIPAA / EDI transaction code include (270, 271, 276, 277, 278, 834, 835 and 837).
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277/997 (X12 Standards) processes of Medical Claims Industry from the Provider/Payer side
• Experience working on the security for the monitoring of medical outcome quality data reporting for HEDIS related data warehouse ad-hoc database reporting.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Knowledge and experience with health plan operations including HEDIS, NCQA, MRMIB, and other regulatory and evaluative studies, medical claims and other healthcare data including ASC X 12 4010/5010 standards, HIPAA Privacy requirements, and other HMO processes, procedures, and data sets.
• Experience with direct data collection for HEDIS measures, identify opportunities for improvement based on HEDIS results.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277)
• In-depth knowledge and experience in full SDLC with RUP, agile and waterfall methodologies.
• Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid.
• Expertise in creating the companion guides on various EDI transactions.
• Strong experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases. Expertise in designing and developing Test Plans and Test Scripts.
• Specialize in HIPAA 5010 implementation including GAP analysis
• Expertise in creating prototypes and mock-ups for user interface designs.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Experience in Business Requirement and System Specifications Analysis.

TECHNICAL SKILLS:

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management: Rational Requisite Pro, Business Modeling, Rational Rose, MS Visio

Defect Tracking Tools: HP Quality Center, Rational ClearQuest

Languages/Standards: SQL, XML, HTTP, Java, HIPPA 4010/5010, ICD9/10, ANSIX12

Methodologies: Rational Unified Process (RUP), Agile, Waterfall

PROFESSIONAL EXPERIENCE:

Confidential, Alpharetta, GA

Sr. EDI Analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Created new database objects like Tables, Procedures, Functions, Indexes and Views using T-SQL in Development and Production environment for SQL Server 2000.
• Experience with HIPAA 4010 EDI gateway healthcare transactions like 270, 271, 276, 277, 837, 835, 834, 820, and 278.Knowledge of HIX (Health Insurance Exchange), HIPAA 5010 transaction set.
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations
• Created Process Work flows, Functional Specifications documents and documented system requirements.
• Works to assess and respond with corrective actions for control gaps found in the UAT for the HIX
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Implemented SDLC which included requirements, specifications, design, analysis and testing using RUP methodology.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Involved with the coders in evaluation of CPT and ICD-9 codes to ensure that the diagnosis meets medical necessity for the specific CPT code.
• Developed business process models in RUP to document existing and future business processes.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 Provide implementation assessment, strategy, and mentoring services for Rational Rose, UML and RUP.
• Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system.
• Interacted with various cross-functional teams on building business use cases, and understanding expenses and revenue stream.
• Analyzed results and EDI ANSI X12 file mapping and reported on standard analysis spreadsheet..
• Performed extensive Requirement analysis and developed use cases and workflows.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Worked with Quality Control Teams to develop Test Plan and Test Cases.
• Interaction with the developers to report and correct bugs.
• Developed Test Plans and Test Cases according to Business Requirements.
• Use HL7 implementation methodology to create specifications, assist with unit testing, and perform integrated testing for messaging between the state Departments of Health and the location office.

Environment: Servlets 2.2, JMS, Java2 (JDK 1.3), STRUTS, JDBC2.0, DB2, XML, RUP, XSL, XSLT, Rational Rose, PL/SQL, HTML, CSS, JavaScript, Cognos, HL7, MS Word, Excel, Access, Project

Confidential, Reston, VA

EDI Analyst/System Analyst

Responsibilities:

• Gathered Requirements, Developed Process Model and detailed Business Policies.
• The SDLC Methodology used was Agile or Scrub.
• Gathered functional business requirements from process owners and developed functional specifications for application enhancements.
• Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as, 835 / 837 transactions.
• Worked with development / technical team members to ensure that the enhancements would meet the defined business requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Embrace agile principles. Support iterative user experience design, involving UX research and UX design at all stages of product development
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Created customized reports with complex calculations that were used to study the potential financial impacts of changes to Medicare and Medicaid payments.
• Perform the mappings between the Workers Compensation/FMLA to the Federal HIPAA standard X12 837, 835, 997 and 277.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
• Acted as a SME for the application team and the Infrastructure team.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• Conferred with Business Users to Gather Requirements for the design and development teams.
• Involved in exporting data from the database to flat files.
• Facilitated Joint Application Development (JAD) sessions, as well as conducted interviews of appropriate business/technical stakeholders.
• Analyzed Business Requirements to produce System Requirements for the technical team using MS Visio.
• Good understanding of Health Insurance portability and accountability act (HIPAA)
• Conducted Business meetings for the claims adjudication process and its work flow.
• Identifying and documenting UML Use Cases with Use Case diagrams.
• Work with business users to define Business, Process, and Data Models to understand the overall business.
• Worked with developers to test the iterations of the system under development (SUD) to ensure it met the user’s needs.
• Interacted and assisted the entire team on the testing tools and processes.
• Written and executed Test cases for the application when in (UAT) Environment.
• Involved in evaluation of the user request for new or modified program to determine feasibility, cost and compatibility with current system, and computer capabilities.

Environment: Facets, Windows 2003, Oracle, MQC, QTP, MQJ Explorer, Facets UNIX, SQL, Rational Suite.

Confidential, Columbia, SC

Business Analyst/System Analyst

Responsibilities:

• Conduced Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Built business requirements into the Medicare Advantage (MA) requirements database and created the Project
• Requirements Document for the three functional areas
• Worked on Performance, Tuning and loading data for fast access of reports in Client/Database. Server balancing, business Rules Implementation, MetaData, Data Profiling.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in
• RationalRose for the Business Use Case and System Use Case.
• Successful in writing the business and system requirements for HEDIS and other health care measures and compliances.
• Responsible for submitting HEDIS rates to NCQA via IDSS portal. Responsible for submitting Patient Level Detail (PLD) files to CMS via Gentran/Edaptive.
• Created current and future state processes, along with prototype BPM solution at medical device company
• Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Responsible for employing the User-Centered Analysis techniques such as Interviews, direct observations, JAD sessions, to understand the business needs (MS Dynamics).
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual(s) for resolution.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release
• Review of high-level design document and low level design of classes and sequence diagrams.
• Ensuring that deliverables were delivered on time as scheduled.
• Responsible for working on HEDIS quality of care analysis at various acute health care settings.
• Responsible for requirements analysis, design and developing technical requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Responsible for creating detailed design reports within MS dynamics.
• Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
• Developed the business anomalies workarounds and described them in documentation and presented the matter to the upper management for review.
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents.
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Responsible for GAP analysis of ICD9-ICD10.
• Responsible for interpreting HEDIS specifications, wrote data element requirements, designed and implemented SAS programs for various projects.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Created customized reports with complex calculations that were used to study the potential financial impacts of changes to Medicare and Medicaid payments.
• Acted as a SME for the application team and the Infrastructure team.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT that would take several man hours to complete via the front end software
• Incorporated HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X12, Implementation and
• Knowledge of HIPAA code sets, ICD-9 ICD-10 coding and HL7.
• Conducted JAD Sessions with Infrastructure management team, SME, policy holders and stakeholders for issues which were open and pending.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Pega Business Process Management (BPM) tool.
• Conducted the FRS and URS reviews and walkthroughs with designers, developers and stakeholders. Also conducted feasibility and adaptability study.
• Responsible for the requirement-gathering phase and project plan.

Environment: Windows, MS Project, MS Office MS Visio, SQL,MS Dynamics, Facets, Oracle, Informatica, Autosys, Quality Center.