SUMMARY:

• Over 7 years of Experience as Business Analyst in Healthcare include understanding of Business Requirement Gathering, Business Analysis, Joint Application Development JAD sessions with clients and referring to accessible documentation and procedure.
• Exposed to Medicare and Medicaid MMIS domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Extensively Knowledge in the Member Enrollment and Billing information.
• Knowledge and Experience on Membership, Billing, Claims Payment Processing in relation to HIPAA, EDI 4010, 5010 X12, ICD - 9 ICD-10, codes 834, 837,835, and 270, 271.
• Strong knowledge of ICD-9/ICD-10 business analyst with healthcare.
• Able to understand and implement Processing ICD-9 ICD-10
• Gathered good knowledge of Medical and Healthcare Standards and Regulatory vehicles such as HIPAA, FDA, ICD, MMIS, EDI, and HL7
• Supported Design, Develop, and Implement (DDI) teams for new Medicaid Management Information Systems (MMIS)
• Detailed knowledge of Medicare, Medicaid, Managed Care, HMO's, PPO's.
• Proficient in EDI Claims Processing, HIPAA Regulations, 270/271 (Inquire/Response Healthcare Benefit), 276/277 (Claim Status), 834 (Benefit Enrollment), 835 (Payment/Remittance), 837 (Healthcare Claims), ASC X12 standards.
• Extensive experience with Medicare (Part A, Part B, Part C and Part D) and Medicaid benefits, NASCO, TriZetto QNXT, FACETS as well as ICD 9 and 10
• In dept. knowledge of Software Development Life Cycle SDLC methodology such as Agile, Waterfall and RUP.
• Efficient in writing Business Requirements Document, Use Case Specifications, Functional Specifications and Workflows.
• Strong knowledge of Use Cases, and Activity Diagram.
• Expert on US Health Care Industry, Electronic Data Interchange (EDI), Health Level 7(HL7) and Health Insurance Portability and Accountability Act (HIPAA)
• Extensive Experience in Functional, Integration, Regression, User Acceptance UAT, System.
• Knowledgeable working with ETL process Extract, Transform and Load of data into a data warehouse.
• Designed and implemented basic SQL queries for testing and report/data validation
• Experienced in client interaction, deep understanding of business systems functionality and technicality.
• Gathered requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML
• Proficient in Developing and executing Test Plans, Test Case, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
• 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
• Excellent working knowledge in Project Life Cycle and clear understanding of Project Management.
• Identify the potential problems, conduct testing and review before the submission.
• Troubleshoot the transmission errors.
• Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements, Change Management identifying, assessing and managing changes
• Used SQL to test various reports and I was involved in different SQL queries and procedures for data validation.
• Track daily data transfers and production schedule.
• Issue & Risk management identifying, managing, mitigating and escalating
• Experience in decomposing high-level information into details and abstracting low-level information
• Excellent business communication, creativity, problem solving, bringing innovative ideas to complex problems and presentation skills. Adapt at creating, editing, and coordinating extensive communication networks, working effectively with internal and external teams, at all organizational levels to keep executive staff and team members apprised of goals, project status, and resolving issues and conflicts.
• Conducted successful projects with the help of teams to achieve deadlines timely and proficiently and also Coordinated and facilitated extensive user interviews and workshops to gather and analyze requirements. Facilitated project meetings, opening lines of communication and promoting cross team interaction.
• Ensure quality assurance and HIPAA standards are met.
• Organized, goal-oriented, self-starter, and ability to master new technologies manage multiple tasks while following through from start to completion.
• Experienced in analyzing business requirement at all stages of Software development of life cycle SDLC
• Understanding of insurance policies like HMO and PPO.

TECHNICAL SKILLS:

Database: Oracle, Ms SQL server

UML and Modelling tools: MS Visio, Bal Samiq, Enterprise Architecture, ERWIN

Requirement Management Tools: IBM DOORS, RALLY, VERSION 1,TFS, ALM/REITesting Tools: HA ALM, TFS, IBM Clear Quest, Bugzilla, SOAP UI

Others: JIRA, Notepad++, Synchrony, Autosys, MS SharePoint, Putty, WinSCP, Metavance, Foresight, Edifecs, Sensentia, Image Retriever

PROFESSIONAL EXPERIENCE:

Confidential, Phoenix, AZ

Business Analyst

Responsibilities:

• Gathering requirements & preparing business requirement documents (BRD) and User stories for the coordination of benefits (COB) enhancement requests.
• Provide support to all the lines of business (Local, Federal Employee Program (FEP), Corporate Health Services (CHS), Inter plan teleprocessing services system (ITS HOST), ITS HOME for multiple production systems, including Metavance (claims processing system), FEP, claims clearinghouse and IVR.
• Worked with other departments on coordination, communication and documentation of system changes.
• Understand and research multiple system interfaces and mapping and research multiple data formats including the HIPAA transactions.
• Monitor daily, weekly, monthly and on request reports to ensure systems are functioning as they should (Metavance cycle reports, CHS outbound reports)
• Perform system research to identify root cause of production issues or to understand impact of desired changes.
• Performing user acceptance testing (UAT) and post implementation review of system changes.
• Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements, Change Management identifying, assessing and managing changes.
• Worked on contract tracking records by documenting and tracking and validating the contacts of the members in Metavance.
• Worked on Metavance which is the Claims processing system for online and batch adjudication, Case management, customer service, Member/subscriber administration, Provider network management and reporting.
• Worked on foresight testing and foresight production tools for uploading the claims and worked on the rejected claims, edit the claims wherever necessary.
• Used Spec builder (Edifecs) for building the test files, supported the production team.
• Verification of the error codes-Current procedural terminology (CPT), diagnosis and HCPC codes in the claims processing system.
• Testing of the Sensentia tool which is the benefit tool purchased by BCBSAZ to make the benefits readily available for the customer service representatives to review the benefits with the member’s when the member calls in, track the discrepancies, document and validate them in Customer solution service (CSS) tool.
• Created custom mapping between ICD-9 and ICD-10 codes of 2017 and 2018
• Experience with HP Quality Center to document, change, and track requirements and also for testing of applications.
• Experience with Image retriever tool to retrieve the original claims and use them for further processing of the claims.

Confidential, Sacramento, CA

Business System Analyst

Responsibilities:

• Conducted walkthroughs with the different department heads to have a deeper understanding of the requirements.
• Analyzed and documented the business requirements and generated reports for the Manager.
• Created and maintained data mapping documents.
• Worked on all the line of business like Medical (Medicaid), Medicare and Cal-Mediconnect.
• Follow up with the end users and developers for user satisfaction and change management if necessary.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives, resolve issues, and reach agreements.
• Involved in weekly meetings with the development team to resolve technical issue.
• Worked on the SOT (source of Truth) to gather the requirements from all the 3 types of lines of business and from the policies and the procedures provided by Care1st.
• Worked closely with SMEs, and identified, analyzed the core requirements and key features of the ongoing project.
• Facilitated user interviews and workshops to gather requirements.
• Worked with the stakeholders to get a better understanding of client business processes and gather business requirements.
• Identifying and understanding the business critical areas from the user perspective.
• Used ALM/REI for writing the requirements and Managed change of the requirements and associated requirements to other requirements for traceability.
• Familiar with tracing and untracing the requirements to the Business requirements in the ALM/REI.
• Responsible for working with the manager and other users and creating Work flow diagrams as per the data analysis.
• Conducted JAD sessions with management, SME, users and other stakeholders for open and pending issues and participated in the identification, understanding and documentation of business requirements.
• Translated Business Requirements into Functional and Non Functional Requirements by analyzing requirements and current workflow and Designed Business Requirement Document BRD, and developed test plans, test cases, test results analysis and reporting, defect management and test status matrices.
• Working closely with Business users in defining the scope, analyzing business requirements and segregating them into high level and low-level requirements for Financial Risk Applications.
• Was involved in working on different capabilities like enrollments, claims, Health Management, finance, providers.

Confidential, Philadelphia, PA

Business Analyst

Responsibilities:

• Involved in gathering the requirements that were critical to the business process flow and using those requirements for the Business Requirements Document (BRD), for the implementation of the NPI in EDI X12 transactions as mandated by the Federal Regulation.
• Created the requirement documents to channel 270/271, 276/277 and 835/837 EDI transactions.
• Worked on Business Requirement Documents, Test Plan, Test Strategy and Schedules. Very good in all the Documentation & Project life cycle Documentation.
• 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.
• Daily Status reports to the Business owner, Project executives & Team.
• Analyzed the existing 820 reports and modified them based on the changes resulting from the Health Insurance Exchange (HIX)
• Developed modules for extracting encounter data from multiple systems, converted to common format, and loaded into a regional Health Information Exchange for regional patient care management and clinical decision support.
• Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions. Worked specifically with 270/271,276/277.
• Extensively studied the Rules & Policies that supported the Health Care Reform requirements.
• Facilitate UAT Testing by providing necessary support to the Business users.
• Analyze and make specific recommendations on improvements that can integrate into the business process.
• Develop Test plan for Healthcare reforms (HIX) and Care and Population Health Management programs.
• Tested Benefit Plans from enrollment stand point and claim processing
• Worked with ETL Team to design the mapping documents for source to data.
• Good understanding of data flow architecture, system integration, database behavior, and testing strategy.
• Extensively use SQL queries for back end testing and also to query the Oracle Database for Data Validation and Data Integrity.
• Documented XML file processing Use case, as well as identified XML file level processing errors.
• Organized and conducted meetings, briefings, demonstrations and wrote minutes of project meeting and Facilitated project meetings, opening lines of communication and promoting cross team interaction.

Confidential, Dallas, TX

EDI Business Analyst

Responsibilities:

• Identified and validated business rules and data elements.
• Created 837 P, I, D claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837 P, I, D, 834, 835, and 270/271.
• Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Worked with Trizetto based software called QNXT to obtain members information.
• Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare and Florida Medicaid.
• Utilize SQL server to run basic queries and obtain necessary data for Medicaid and Medicare Encounters.
• Using SQL query to produce data for 270 EDI X12 file, and create 270 files and submit to MEVSNET to check dual snip member for Medicaid benefits.
• Review vendor files for any errors, missing segments, and for missing data on X12 file. Ensure file has complete data before claim can be submitted to Medicare and Medicaid.
• Develop error processes to interrogate EDI error responses / rejects so that data can be processed successfully.
• Address unfamiliar questions and track down the answers through data tracing and on the ground learning of core systems.
• Analyzed Impact analysis when there is any change in the requirements and updated the Business Requirements Document BRD and Systems Requirements Specification SRS .
• Facilitated meetings with the technical team and client team to analyze the current process and gather requirements for the proposed process.
• Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 271HIPAA EDI Transactions using MS Word, MS Excel, MS Access and Facets
• Streamlined Claims 837 EDI X12 Migration project by gathering functional specifications in Edifecs
• Tracked the change requests and decomposed business processes to identify issues and range of possible solutions.
• Have utilized Requisite Proto import word and excel documents in different extension formats. i.eexv, csv comma delimited file, tab delimited file.
• Have utilized Clear Quest to repair and detect errors in a program.
• Maintained and tracked the project plans using MS Project.
• Daily and weekly status reporting to senior management.

Confidential, Lansing, MI

Business Analyst

Responsibilities:

• Involved in all phases of software development life cycle in RUP framework and worked in the RUP environment for the elicitation, representation of requirements and in change management.
• Performed requirement analysis by gathering both functional and non-functional requirements based on interactions with the process owners stake holders and document analysis, represented them in requirements traceability matrix RTM using Requisite Pro. Performed user interviews, JAD sessions.
• Assessed the flaws in the existing as-is system and made clear recommendations of Business process improvements and BPR, incorporated them in the future to-be system design.
• Participates in development sessions and design reviews in order to ensure design meets user requirements
• Extensively worked on claims processing and with HIPAA in different EDI healthcare transactions 837, 835,834, 820, 270, 271, 276, 277 and 278, file transfer success/failure.
• Worked on Batch processing, member, subscriber enrollment module of 834, ID card generation processes and Created business process flow to capture the required data in future, define business rules to determine Medicare Part C and Part D Member Coordination of Benefit letters as required by CMS, Medicare Secondary Payer for members with Workers Compensation,
• Involved in FACET configuration, Customization, reporting, analysis and enhancement and also worked on membership, claim module.
• Reconfigured and customized FACETS applications for groups, sub-groups, types of plan, pricing and provider to expedite benefit enrollment process and to ease claim processing.
• Extensively worked on EDI 834 on FACETS to customize and configure membership benefit enrollment data files according to the need of the proposed system.
• Responsible for reviewing and modifying process flows to increase productivity and effectively utilize FACETS features not provided by the legacy systems.
• Performing business analysis for a web-based Management Information System MIS designed to support critical reporting functions for customers of the Centers for Medicare and Medicaid Services.
• Wrote user requirements specification (URS) and Functional requirements specification (FRS) Documents as per the Business requirements and process flow.
• Helped to identifying potential problems quickly, before they occur and interacted with customers providing product information, product use information, and technical assistance on web sites that are accessible 24 hours a day, 7 days a week.
• Developed UML Use Cases for the application using Rational Rose and prepared the detailed Work flow diagram based on the proposed enhancement for the system and also developed Process DFD and Data ER models for the as-is and to-be systems.
• Actively involved in the UML based Class, Communication, structured charts, Class and sequence diagrams activity Diagrams for certain modules of the application in collaboration with Design Team.
• Involved in Deployment of Crystal Reports and production support. Significantly involved in created reports using BI tools like Business Objects.
• Experience with HP Quality Center to document, change, and track requirements and also for testing of applications.
• Developed modules in the HR department for the user education and training about the new web based system.

Confidential, Bronx, NY

Business Analyst

Responsibilities:

• Independently studied ICD-10 requirements and studied the changes to be implemented using the General Equivalence Mapping (GEM)
• Performed forward and backward mapping between the two standards and documented the required changes.
• Worked with 834 (enrollment), 835 (medical claims payments), 837 (medical claims), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), and 277 (claim status response).
• Conducted meetings, Joint Application Development (JAD) sessions and interviews with the business users to gather requirements.
• Involved in the processing of the claims on the NASCO and then sharing the test results with the business according to test acceptance criteria during their UAT phase.
• Created Business Requirement Document (BRD) for the whole project.
• Created use case diagrams, activity diagrams, and flow charts to depict the interaction between the various actors and the system.
• Worked on the database analysis part by helping the technical team in identifying the data sources required for the application and coordination with the IT team in migration of the data within the databases.
• Developed non-functional requirements and documented them to be presented to the technical team
• Helped the QA team in writing the Test Plan and conducting the quality assurance phase.
• Worked with the QA team in testing the application using HP QTP.
• Determined the requisite ICD 10 training for both internal staff and Medicaid provider groups and assisted in the development of training materials.
• Logged application bugs and was involved in all stages of the bug life cycle.
• Dealt with Project lead, stakeholder and end-users regarding any issues encountered during the project.