SUMMARY:

• Over 7 years of professional experience as Business/System Analyst with expertise in Software Development Life Cycle (SDLC) in Health Care Sector with prime focus on EMR, HL7, claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Extensive experience in training corporate and independent clients on subjects like Business Analysis, Business Process Modelling and other core areas of Business Analysis like, Enterprise Analysis, Effective Requirement Gathering, Skills to survive as a BA(for clients on job) and SOA(Service Oriented Architecture). Also worked on legacy modernization methodology including the tasks, models and techniques.
• Experience with health care Systems: FACETS
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre - Adjudication)
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS.
• Having excellent knowledge and worked as a SME on Medicare, Medicaid, Medicare Advantage, MediGap, HIPAA Standards (HL7), EDI Transactions (4010), ICD-9 and ICD-10 Codes, and FACETS Healthcare Platform. Also, used Clarity PPM (Project Portfolio Management) to provide industry best practices for utilizing the Clarity product.
• Highly analytical in developing the methods and measures to meet requirements and solve any issues that arise during the project.
• Proficient in the use of tools like Telelogic DOORS, Rational Rose, Requisite Pro, Rational ClearCase, Telelogic System Architect and MS Visio.
• Well experienced in CMMi, SDLC, and Agile development methodologies. Healthcare domain and experience in areas of Healthcare EDI transaction sets (834,835,837i/p, 820, 997/999), HIPPA, ACA and Health Insurance Exchange. solution to the customers for Facets Production Issues.
• Supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• 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.
• Experience in requirements gathering for development of the customer MDM data models.
• 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, Medicare Part A, B, C, D, Medicaid systems.
• 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.
• Driven by creative ideas and backed by strong Analytical and methodical problem solving skills, identifying causes, corrective actions and providing innovative solutions, building strategic partnerships with senior business leaders and getting commitments to actions from individuals at all levels.
• Extensive experience on Excel, Word, PowerPoint, MS Project, MS Visio, Rational Suite and SQL.
• Highly motivated self-starter with excellent communication, presentation and interpersonal skills, can perform well both independently and with a team, always willing to work in challenging and cross-platform environments.

TECHNICAL SKILLS:

Business Tools: Retalix, Proxis Store Manager Classic, TeleTracker Business Suite, PRAPP

Microsoft Tools: MS Project, MS Visio, MS Office, MS Outlook, MS FrontPage

Databases & Languages: Oracle, MS Access, .NET, MySQL, SQL, HTML, MS Visio, Rational Suite (Rose, RequisitePro, RequisiteWeb,ClearCase, ClearQuest) Java, Doors, XML

Testing Tools: HP Quality Center, Mercury Test Director, WinRunner, Load Runner, Rational Robot, Quick Test Professional

Methodologies & Standards: RUP, Six Sigma, SDLC Agile, QA, HIPAA, Medicare Software, ezclaim, Medicaid, SOA, CMM, CMMI, PMBOK

Operating System: Windows 95/98/NT/2000/XP, UNIX, Linux

Tools: Adobe Acrobat, Business Explorer, Toad, Data Warehousing, Lotus Notes

Skills: Rational Rose, Rational Requisite Pro, Rational Clear Quest, Snagit, Rational Unified Process, UML, SOA, Business Process Modeling, MS Visio, MS Word, MS Excel, PowerPoint, MS Project, MS Access, MS Outlook, ERWin 4.5, SharePoint, Cognos, Crystal Reports Visual Basic 6.0, Java, Object Oriented Programming, C++ .Net, UNIX, Windows NT/ 2000/ XP, MS SQL Server, BlueChip, FEP Express, VDR Data System, BlueSource, Coordinator Mouse.

PROFESSIONAL EXPERIENCE:

Confidential, NYC, NY

Sr. Systems Facets Analyst

Responsibilities:

• Assisted in the Project manager in creating and updating the Vision Document, Business case, and the Project Plan to define Objective, Scope and Risks. Also assisted in creating RUP iteration plans and phase plans
• Elicited requirements, and managed Change Configuration to maintain an orderly procedure for managing requirement changes after sign off
• Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
• Followed AGILE methodology viz. Scrum throughout the project.
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health Insurance.
• Experience with BlueCross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12, 4010 and 5010 ICD9 and ICD-10 implementation guidelines & electronic formats including 270/271, 276/277, 700, 701, 810, 820, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications including NEIC, SSI, ESI, Datatrac, Medtrac, Cube, BlueCross, Medicare, and several others using COBOL, Metafile, Visual Basic, Unix, DOS, Assembler, C, FTP, Windows, Novell, and various other communication packages.
• Created Heat map with alert mechanism. Various KPI graphs were drawn. Kept eye on Qlikview best practice
• Project entailed developing a data model based on MS SQL Server and Tableau Server.
• Worked as Subject Matter Expert (SME) for various projects. Taught the users to get along with Qlikview.
• Elicited functional specifications, conducted feasibility analysis, and performed impact analysis
• Elicited Business Rules and other Non-functional specifications for the new system by interviewing the Subject Matter Experts (Doctors & Nurses) to further understand the business models
• Authored functional specifications for different HL7 system interfaces: ADT (registration), SIU (scheduling), OMG (rad order entry), and ORP/RDS (Rx processing)
• Designed, developed, and implemented innovative & sustainable Tableau reports. Supported effective rollout of reports, including training collateral
• Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
• Responsible for positioning and delivering QlikView projects and cross building applications into new and existing customer base
• Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Gathered requirements from the clients and developed crosswalks for 277/288, 834, 835, 837 P/I claims
• Created Request For Proposal to identify possible vendors and obtained cost and functionality information
• Created UML Activity Diagrams to depict business processes (AS-IS and TO-BE) and analyzed them for their efficiency and productivity.
• Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time transactions like 270/271/276/277 for Medicare and Medicaid programs in FACETS.
• Tracked UAT issues/bugs and prepared reports.
• Developed test cases based on the crosswalks and compliance guidelines for 277/288, 834, 835, 837 Professional, Institutional and Dental claims and for 270/271 eligibility benefit inquiry and response
• Created Use Case Model using Rational Rose for developers and other stakeholders to understand the business process, depict roles, and procedures
• Daily management activities included educating portfolio managers, financial analysts and risk managers on the cost of third-party financial research using business intelligence dashboards from Tableau Software.
• Decreased customer complaints and dramatically reduced post-implementation support. Involved in forming strategy for increasing call conversions.
• Worked on customizing the claim module of FACETS for reprising Nursing home claims.
• Reviewed analysis of call center’s achievements of key client goals, ensuring continuous and consistent performance
• Data mapping on Enrollment Module (EDI 834) of FACETS.
• Experience in integrating claims, eligibility, provider and data information using facets.
• Facilitated requirement-eliciting sessions (JAD sessions) with Subject Matter Experts and other Key Users and documented the requirements in an easy to understand format by both the business and technical personnel
• Constructed Use Cases and Wireframes and translated them into a Functional Requirement Specifications document
• Expertise in iterative approach of AGILE development with all the teams members
• Involved in all phases of Software development life cycle (SDLC) using Agile Scrum methodology.
• Establish documentation for agile methodology for implementation with a very water-fall-centric development team.
• Performed manual testing, including validation/smoke testing of HL7 interface messages on each new build before delivering to quality assurance team
• Coordinated daily activities with the IT Developers, QA and Product teams along with the project management group.
• Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data
• Generated test data using X12 generator for transactions 277/288, 834, 835, 837P/I/D. Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
• Created Online User Guide comprising different scenarios, screenshots, and troubleshooting procedures

Environment: MS Project, MS Excel, MS Word, Rational Rose, Agile, MS PowerPoint, Facets, Tableau, UAT, Oracle 9i, QlikView, Citrix (server), Epic

Confidential

System Facets Analyst

Responsibilities:

• Developed the High Level Project Requirements (HLR) for a very large project.
• Modified and used Project Templates to gather the requirements and carry on the project. Also worked on legacy transformation methodology including the tasks, models and techniques.
• Worked on FACETS for healthcare plan administration. Also, experienced on claims adjudication to provide the best claims management service.
• Worked as a SME on Medicare, Medicare Advantage, MediGap, HIPAA, HL7, EDI Transactions and all other compliances.
• Coordinated the project team for JAD and BRD Sessions.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, information needs and insured that critical requirements are not missed
• Worked on FACETS for healthcare plan administration. Also, experienced on claims adjudication to provide the best claims management service.
• Followed solely RUP methodologies during the course of the project.
• Coordinated activities between business unit and technical staff, developed new methods, policies, and procedures to meet the business needs.
• Developed EDI application interfaces for Shipment Order Requests (850, 940, 856s) with Expeditors for Goldbug’s warehouses.
• Created and corrected EDI 850, 856 & 810 maps using Gentran:Server for Windows/Application Integration software interfacing data to/from JDEdwards ERP package.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.
• Performed Requirement Analysis by gathering functional requirements and represented them in Requirements Traceability Matrix (RTM) using RequisitePro.
• 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.
• Participated in Facets Table data modeling, planning, designing, implementing the data warehouse and conducted testing by developing complex SQL queries.
• Prepared Functional Design Specifications (FRS) employing Use case scenarios, sequence diagrams, DFDs and class diagrams.
• Defined maps to customized claims daily load into Facets for processing the transactions.
• Identified and clearly defined functional issues and supported IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.
• Documented and assisted the QA Team with the Test Plan.
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• Developed Data Conversion Strategy using ETL functions for converting data from the existing site to the new site.
• Assisted Project Manager to complete the project approval process.
• Developed the prototype for PDA application “Rehab without walls” for interfacing with billing and invoice application
• Migrated EDI traffic (X12 docs 850, 856, 810, 830 & EDIFACT messages DESADV, DELFOR, DELJIT) of Henkel Loctite Canada & Henkel Surface Technologies Canada from their legacy applications to the new SAP ERP system.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Worked on ‘FACETS Healthcare Solution’ to make the organization efficient in responding quickly and effectively to the change around the healthcare market.
• Developed Templates to gather the requirements for applications to be added in SATS
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, information needs and insured that critical requirements are not missed
• Involved in planning, execution, coordination of entire testing (QA) life cycle
• Developed strategies for Test Planning, Test Case Designing, Test Scheduling, Test Estimation, Test Execution and Defect Tracking
• Assisted the QA team in SIT and Business in UAT

Environment: HTML, XML, MS-Project, load runner, Agile method, Sharepoint, Contact center, Facets, MS-Office Suite, Rational Suite, Doors, RequisitePro, RequisiteWeb, UML, IBM WebSphere, Microsoft Visio, SQL/PLSQL,SQL Server 2005, Rational tools

Confidential, Pennsylvania, PA

Business System Analyst

Responsibilities:

• Led a team of business analysts both onsite and offshore within the Correspondence Report Competency Center at Medica for the Phoenix program.
• Gathered requirements for correspondence and report generation from functional and business owners and converted these requirements into User Stories.
• Participated in all Iteration, Scrum, Daily stand-ups and Iteration review meetings working in an agile development methodology.
• Led Sprint Planning meetings, getting estimates from individuals (BA’s) and assigning tasks based on velocity/capacity.
• Coordinated the upgrade of EDI Transaction Sets 837, 835 and 834 to HIPAA compliance. Work on EDI 834-file load in Facets through MMS (Membership maintenance sub-system).
• Closely worked with all BA’s and stake holders for reviewing User Stories and scoping documents.
• Gathered requirements from carriers, interpreted XML documents and created mapping documents.
• Coordinated with Minnesota Health Exchange (HIX) program staff and other stakeholders to define and develop requirements for correspondence generation across various business lines.
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• Analysis and Design of the FACETS data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed (837P, 835, 834)
• Practiced agile methodology, led sprints and prioritized line items based on key business initiatives with respect to the ACA mandate and Health Care Reform Act
• Led JAD sessions with subject matter experts (SMEs) from each work stream/business unit for particular correspondence lifecycles, process flows, and triggering conditions etc. for development within the HP Exstream environment; translate business requirements into a functional document and solution design.
• Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared Business Requirement Documents (BRD) using Rational RequisitePro.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Standardized and validated data tags, created data dictionaries for new and existing correspondences and reports for the purposes of data analysis.
• Worked closely with HP Exstream and Health Rules developers to understand system specifications.
• Helped develop integration solutions that create interoperability between Health Rules and HP Exstream.
• Tracked user stories, tasks, burn down hours and project progress in Version 1 efforts across various work streams, participate in daily scrum meetings, provided status reports, impediments and milestones to scrum masters to meet tight project deadlines.
• Raised issues and escalations in IRAAD as possible threats to project deadlines.
• Led Member Experience Review Boards to gather a user experience perspective on content, usability and readability of correspondences. Liaison closely with content writers to align the content to specific and unique business needs.
• Involved in claim adjudication process of facets application
• Devised workarounds and made recommendations to solve intricate problems eg. system capacity and limitations, operating time.
• Worked with Quality Assurance team to validate system acceptance and user acceptance test plan (UAT) and test scripts.

Environment: Rational Suite (Rose, RequisitePro, RequisiteWeb), Rational Unified Process (RUP), Informatica, facets, Windows XP/2000, Doors, Oracle, IBM WebSphere, SQL, System Architect, MS-Project, MS-Office Suite, MS Visio, MS Word, MS Excel

Confidential, Aurora, Colorado

Business Analyst

Responsibilities:

• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Met with individual departments to communicate SharePoint purpose, application and vision for the future
• Experience with HIPAA Act Rules and regulations & HIPAA transactions
• Created different users, roles, Document libraries, Form Libraries, Team sites for projects, Issue Lists on SharePoint Server 2003
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Understood the relationship of various FACETS table involved in the project.
• Analyzed and validated results of various FACETS tables involved in the batch process using SQL and PL SQL in Oracle SQL Developer and TOAD.
• Completed the documentation of Claims Scenario’s for the source system
• Developed data cleansing and data auditing procedures to clean external data and provide audit logs of rejected data.
• Generated EDI specifications using EDIFECS SpecBuilder for all the transaction sets exchanged with Mervyns.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using Microsoft Visio.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.
• Documented entire EDI Infrastructure and all of the EDI processes
• Designed conceptual and logical data models of Data Warehouse and tables.
• Using Shared Containers and creating reusable components for local and shared use in the ETL process.
• Verified the Business Scenarios on new builds to allow extended testing by the QA team.

Environment: .NET, Oracle 10g, Facets, MS Office Tools, IBM WebSphere, MS Visio, Lotus Note, Outlook, Share Point, Citrix, TOAD.