PROFESSIONAL SUMMARY:

• Healthcare Business Analyst/ Facets Configuration Analyst with 8 years of experience in the Healthcare Industry on various areas like Claims Processing, Configuration, Billing, Insurance and Reimbursement, Medicaid and Medicare Services, and Pharmacy Benefits Management.
• Over six years of consistent experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, System Change Document, Functional Specifications, experienced in writing Use Cases.
• Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be'/'Go-To' processes.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Experience with TriZetto Facets 4.21/4.31/5.01 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Experience in Mapping ICD 9 codes with corresponding ICD 10 Diagnosis and Procedure Codes.
• Experience in developing and imparting pre and post implementation training, conducting GAP Analysis, User Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis.
• Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820Companion guides.
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements.
• Strong experience with different project methodologies including Agile-Scrum Methodology, Waterfall, Modified-Waterfall, Iterative, Incremental and RUP.
• Provide AGILE project management controls, project plans, timeline schedules, facilitate RAD sessions, and review software defects.
• Responsible for providing business requirements within an AGILE software development SCRUM environment.
• Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834 (Benefit Enrollment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820 (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response)
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams.
• Contributing to software process-reengineering efforts aimed at evolving current software development practices to adopt Lean/Agile
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• 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.
• Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.
• Defect Management / Bug Fixing - Fully involved in the process of defect identification and resolution using tools like Test Director, Clear Quest, and Quality Center.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.
• Strong Management and Communication Skills, demonstrated proficiency in leading and mentoring individuals to maximize levels of productivity, while forming cohesive team environments.

TECHNICAL SKILLS:

Test Analysis: Functional Requirement Gathering & Analysis, Analyzing Business Rules, Test Flows, Test Planning, Causal Analysis of Defects,System Change Request, Impact Analysis

Test Management: MS Project Test Scheduling, Test Director, HP Quality Center, ALM, TSS

Traceability Matrix for Requirements and Defects

Testing Methodologies: Object Oriented, Keyword Driven and Data Driven testing, Top to Bottom and Bottom to Top test methodology, Requirement based, Risk based, Priority based test methodology

Mercury Interactive: Unified Functional Testing11.0/11.5, Quick TestPro9.5/9.2/8.0, Business Process Testing,, TestDirector9.0/8.0/7.5, HP Quality Center

ETL Tools: Informatica 7.1/8.x, SSIS 2008

IBM Rational Suite: Rational Functional Tester 8.0/7.0

Bug Reporting: Rational Clear Quest, Test Director,JIRA

Version Control: Rational Clear Case 7.1/7.0.1/7.0.0

Scripting languages: VB Script, HTML, Shell Scripting

Operating Systems: Windows XP/NT/2000/Vista/7, DOS, UNIX

Databases: Oracle 10g/9i, MS SQL Server 6.5/7.0/7.5/2005, IBM DB2, TeradataV2R6, MS Access

MS Suite: MS Office 2007 (Word, Excel, PowerPoint, Outlook), MS Visio, MS Project

PROFESSIONAL EXPERIENCE:

Confidential, FL

Business Analyst / Facets Configuration Analyst

Responsibilities:

• Participated and organized requirement gathering sessions with the stakeholders to elicit and analyze requirements.
• Assisted in preparing Scope Document by analyzing - various business domains interdependencies, end to end business processes of claims adjudication, various business domains scope statement, current business process flows and current system documentations.
• Designed, developed, tested and deployed Accounts Receivable Universe
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Wide-ranging experience in using methodologies such as UML (Unified Modeling Language), Agile, RUP (Rational Unified Process) & Waterfall using rational tools and Microsoft Suite.
• As Agile Scrum coordinated Sprints, from Iteration Planning thru daily scrum, and Iteration Reviews and Retrospectives.
• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Performed Quality Assurance of new or existing contracts and configuration to ensure appropriate or correct payment was made via unit testing.
• Maintaining knowledge of Medicare and South Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Worked on Scrub enhancement project related to Medicare Part D.
• Completed several HIPAA 4010 and 5010 Projects, included Medicaid and Commercial entities.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Coordinated and worked with Project Manager to prepare Project Plan in MS Project for Process Claim Domain.
• Involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834.
• Documented business needs for ICD 10 resulting from the HIPAA 5010 gap analysis.
• Responsible for updating clients with provider information within MMIS on a weekly basis by running queries and exporting data in a defined file formats.
• Proven experience with Agile (Scrum) and Waterfall Development Life Cycles (SDLC) methodologies.
• Experience in testing the claims Adjudication Process using Facets 5.01.
• Performed GAP analysis for ICD - 10 and EDI .
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims
• Prepared SSD (Solution Summary Document), HLD (High Level Design Document), SRI (System Requirements Inventory), RTM (Requirement Traceability Matrix) and also created BRC (Business Rule Configuration).
• Executed complex integrated systems planning and solution alternative analysis and design.
• Executed business process analysis “As-Is” system & “To-Be” systems & perform gap analysis.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system).
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Identification of problems found within FACETS 5.01 and when testing the SQL data database
• Created keyword files to have member data bulk loaded into the FACETS system through the MMS batch
• Experience in developing, validating and implementing SAS programs and produce derived datasets for analysis and generating & documenting tables, listings and graphs for clinical study reports.
• Wrote test cases and test scripts for the User Acceptance testing

Environment: MS Visio, Transaction Management, Microsoft SQL Server, Quality Center 10.0, IBM DB2, Sybase, TriZetto Facets, MS Word and MS Excel

Confidential, MI

Business Systems Analyst

Responsibilities:

• Analyzed Business Requirements and segregated them in to high level and low level Use Cases, Activity and Sequence using MS Visio according to UML Methodology.
• Prepared Crosswalk documents for ICD 9 and ICD 10 Procedure and Diagnosis codes.
• Conducted JAD sessions with project's stakeholders such as users, QAs and project management team to identify and resolve issues.
• Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
• Conducted Claims and HIPAA Compliance Training to run the test cases. Also worked with NPI
• Experienced in X12 transactions 835/837/834/820/271 of medical claims/underwriting for support and point of reference for the vendor in business issues.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML.
• Created stored procedures and used ETL tools to automate activities for extraction, transformation and loading into the corporate data warehouse.
• Manage 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. Understand and articulate business requirements from user interviews and then convert requirements in to technical specifications
• Facilitated User Acceptance Testing (UAT) with stakeholders and the business users.
• Frequently updated the requirements and defect status as per the current status of the Testing project in the Clear Quest.
• Project Management and Controlling to ensure on time delivery using MS Project.
• Used guidelines and artifacts of RUP to strategize the implementation of the Rational Unified Process effort in different iterations and phases of the Software Development Life Cycle (SDLC).
• 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.
• Coaches and mentors Agile team members coached 5 teams (total of fifty four team members).
• Worked on Health care Eligibility and Benefit, Claim Status transactions 270/271, 276/277, 835, 837 based on the HIPAA compliant ANSI X12 version 4010/5010
• Documented the Use Cases and prepared the Use Case and Activity Views using MS Visio and Rational Rose for a clear understanding of the requirements by the development team.
• Developed timelines for project delivery, and managed projects and resources to successful completion.
• Involved in writing Data Mapping Documents for the system and involved in documenting the ETL process and writing SQL Queries for the retrieval of the data
• Performed Data Analysis on the extracted data, data cleansing and scrubbing.
• Validated the database by applying business rules using SQL queries
• Implement Data warehouse processes like Data Extraction/Transformation and Load (ETL).
• Updated Topic Papers to Include enhanced functionality and got end users sign off.
• Performed GAP and Risk analysis of existing system and evaluated benefit of new system.
• Conducted project related presentations and provided reports to the higher management.
• Worked closely with PMO in all the phases, Project Initiation, Project Planning & Design, Execution & Build, Implementation, Project Closeout
• Extensively involved in using of formula fields, parameter fields, Group selection and record selection in Crystal reports 7.0.
• Conducted workgroup sessions with client and security team to analyze system role-based access and panel security.

Environment: MS Office, MS Visio, Rational Rose, ETL, Crystal Reports 7.0,SQL Reports, Rational Unified Process (RUP), RMLC, UML, Java, HPQC, JSP, HTML, Oracle8i.

Confidential, KS

Business/System Analyst

Responsibilities:

• Work closely with Business Owners and Stakeholders to outline Business Requirements.
• Work with Business analyst and IS teams to understand the flow of data.
• Gathered legacy business requirements by shadowing Customer Service Representatives (CSRs), Customer Relationship Representatives (CRRs), preparing questionnaires, to identify limitations in the current system and GAPS in the proposed system.
• Participated in management level status report meetings, in addition to participating in concept, design, build and implementation of Pega Modification Portal.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Designing test scripts for testing of Claims in Development, Integration and production environment.
• ICD-10 remediation in alignment with GEM Mapping, Reimbursement Mapping, and Forward/Backward Crosswalk concepts.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Validated the following: 834 (Health Care Claims or Encounters), 834 (Health Care Claims payment/ Remittance).
• Elicited, documented, verified, and validated all Pega Modification Portal letter requirements.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) report.
• Worked in an Agile Development Environment fractioning out the functionalities of Electronic Health Record (EHR) and Practice Management and Insurance verification.
• Performed detailed analysis for the following functional areas that is going to be impacted by ICD-10 codes.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems as well as for ICD 9 to ICD 10.
• Conduct ICD-9/ICD-10 conversion analysis through ICD 9 and ICD 10 proposed mapping documents and HIPAA 5010 system capabilities of EDIFECS tools. Update mapping documents as required for version upgrade and change requests.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models.
• Carefully influenced and worked with all Pega Modification Portal actors like Openers, Relationship Managers, Underwriters, Quality Assurance, Final QA and Closing and helped write requirements, design documents, design software specifications etc.
• Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Used Rational Rose for creating the Use Cases Diagrams, Activity Diagrams, Class Diagrams, and Sequence Diagrams etc.

Environment: Windows 2008/XP, UNIX, MS SQL Server, HP QC/ALM, HIPAA Standards, FACETS, MS Visio, MS Project.

Confidential, Bronx, NY

Jr. Business Analyst

Responsibilities:

• Engaged with clients to understand business processes and determine their specific requirements.
• Elicited and documented Business Requirement Document (BRD), Functional Requirement Document (FRD) and System Requirement Document (SRD).
• Developed, communicated, and validated requirements package with business and developers.
• Facilitated Joint Application Development (JAD) Sessions for communicating and managing expectations among the Stakeholders.
• Identified the Business processes for developing and documenting detailed business requirements.
• Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
• Made regular status presentations to senior management and walked the stakeholders.
• Worked collaboratively with Developers, Testers to perform a gap analysis of the company’s existing system functionalities.
• Validate EDI Claim Process according to HIPAA compliance and tested HIPAA regulations in Facets HIPAA privacy module.
• Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Tested the HIPPA EDI, 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.
• Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated the scripts to make sure they have been executed correctly and meets the scenario description.
• Extensively worked on all kind of joins and operators to fetch data from multiple tables.
• Created and maintained SQL Scripts to perform back-end testing on the oracle database.
• Worked with the client to create and execute the acceptance test strategy.
• Obtained signoff from project stakeholders on tasks completion

Environment: MS Project, MS Office, Quality Center, UML, JAD, SQL, SDLC, sqlagile, Scrum, and HIPPA