SUMMARY:

• Results - driven, versatile consultant with over 7+ years’ experience as a Business Analyst.
• Specialized in Healthcare, Insurance, Risk and Compliance, Document management.
• Good knowledge of Business Analysis methodologies, Iterative and Incremental Software Development Life Cycle (SDLC) using Rational Unified Process (RUP).
• Proficient in gathering business and technical requirements from both formal and informal sessions through interviews, NetMeeting, questionnaire, video conferencing, JAD sessions and conference calls.
• Strong knowledge of Use Cases, Sequence Diagrams, Collaboration Diagrams, Activity Diagrams, and Class Diagrams.
• Hands on knowledge of various Health Care standards/requirements like HL7, CCHIT, Meaningful Use & Stimulus Program, HITSP, PQRI, HIE, CQM, DICOM, ISO, IEEE.
• Experience in developing Test Plan and Test Cases as per the business process requirements to match the functionality requirements and UML diagrams.
• Possess very good organizational skills, with the ability to multi-task and deal with shifting priorities.
• Experience in Claims Processing, Claim encounters and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
• Experience in EDI (270,271,835,834,837) transactions.
• Sound analytical and problem solving abilities.
• Worked on healthcare standards such as HIPPA 4010, 5010, DICOMM, CPT, ICD-9 and SOAP.
• Expertise in ICD-9 to ICD-10 Conversion.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR (continuity of Care Record), CCD (Continuity of Care Document), NCPDP Script 8.1, ELINCS, and CDA.
• Worked on various Professional billing and Hospital billing products.
• Experience in working with HHS, CMS or Medicaid Programs, RHIOs, IHDNs.
• Knowledge on medical necessities, software validation and healthcare compliance auditing.

TECHNICAL SKILLS:

Methodologies: RUP, Agile, CMMI, CMM, Six Sigma, OOAD, UML, Business Modelling, Process Modelling and Data Modelling.

Office Tools: MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, Lotus Notes.

Process/Modelling: MS Visio, Rational Rose, Rational Requisite Pro, Smart Draw, Clear Case, Clear Quest.

Testing Tools: Test Director, Quality Centre, Win Runner and Selenium

Operating Systems: Windows 7, Vista, NT/2000/2003/ XP/98

Quality Management: HIPAA, CMMI, CMM, Six Sigma, TQM

Languages: C/C++, Java, SQL, PL/SQL, HTML, XML

Database: MS Access, SQL Server 2000, Oracle 9i & 10g, Teradata

Other Tools: Macromedia Dream Weaver, Macromedia Flash and Adobe Photoshop.

PROFESSIONAL EXPERIENCE:

Confidential, Philadelphia, PA

EDI Analyst

Responsibilities:

• Understand the overall Encounters process
• Created a Business Requirement Documents from the State and LOB contract obtained from the state website.
• Created complete Encounters process flow diagrams from scratch in MS VISIO.
• Assisted JAD sessions to identify the business flows and determine whether the EDI X12 Transaction, Code set and Identifier aspects of HIPAA, impacts any current or proposed systems.
• Implemented enterprise integration strategies for HIE(Healthcare Information Exchange), CCD (Continuity of Care Document), Medical Summary, PHR( Personal Health Record).
• Created Encounters policies and procedures documents including the process flow, explaining in detail all the process steps.
• Developed the strategy for developing and implementing new EDI (HL7 and X12) interfaces and converting historical clinical and data.
• Worked on ICD 9/10 codes, HIPAA regulations, SOX compliances and EDI 278, 835.
• Expertise in Healthcare, Health Information Exchange (HIE), Electronic Health Records (EHR), Electronic Medical Record (EMR), Electronic Data Interchange (EDI) and HIPAA regulated environment projects.
• Used RACI system to update the process steps in the entire flow.
• Created detailed Desk procedure documents for each LOB using Ops guides from the Encounters IS team.
• One on one session LOB’s and Review meetings was held with the Encounters Analysts of the respective to proceed and complete the documents.
• Co-ordinated with the offshore team in creating the formats and mapping the process flows between high level and the newly created.
• Made efforts to make sure all the basic process flows and document templates were being followed closely and all looked similar except for few state requirements varying form LOB to LOB.

Environment: MMIS, Medicaid, Encounters Process (837/835/999/277 ), MS Project, Microsoft Visio, Windows 7, SQL, Data Ware House, BO

Confidential, New Jersey, NJ

EDI Analyst

Responsibilities:

• Understand the Business, Model and Products of DDNJ.
• Created a Feasibility study report which was already conducted using the supporting notes provided.
• Created Vision and Scope document with all details of the project clearly mentioned.
• We were the first team in the company to implement Requirements management plan and charter in the Project Planning Schedule.
• Create and test maps within interface engines to perform necessary EDI transformations.
• Develop, analyze, and test interface specifications in compliance with departmental and vendor standards for implementation of EDI transactions.
• Analysed Impact of the project on the existing systems, other projects and documented it.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Coordinated and conducted JAD sessions and one-on-one sessions as part of Requirements gathering process with Business Stakeholders and SME’s.
• Created overall high level process diagram and broke it down to individual process diagrams and flowcharts for use along with BRD’s and FRD’s using MS Visio, MS Project and MS Word etc.
• All Business and Functional requirements were uploaded in ALM tool for the testing and developing team to be able to view the same document, work or comment at the same time as a BA can.
• Coordinated with developing team located in Ireland over the phone in performing a gap analysis of the existing Billing system WISDOM and ICE and highlighted the functionalities required to be updated in ICE as in WISDOM or add more as the Business requires
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicare, and implementation of HIPAA key EDI (ANSI X12) transactions
• Huge Integrations of the third-party systems for Billing presentment portal, Commissions Portal and Dynamics AR maintenance were incorporated into the process diagrams and flow charts.
• Participated in Project strategy meetings, assessment and Project planning.
• According to the new laws DDNJ is gearing up with up-gradations and is working on Healthcare Reform. Website modifications and salesforce linkups along with EDI updates are being followed up.
• Provided Business Specs in the form of BRDs for EDI transactions 834, 835 and 837.

Environment: MS Project, Microsoft Visio, HP ALM, Windows 7 and SQL

Confidential, MD

EDI Analyst

Responsibilities:

• Assist with creation and maintenance all necessary documentation and training materials for Epic Ambulatory application
• Performed analysis, design, development and maintenance of the Epic Ambulatory applications and other clinical information systems
• 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 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Interacted with the DST (off shore) teams for QA support and training purposes. Responsible for running test region EDI loads on AS400 Series. Updated records in AS400 before processing for testing purposes.
• Excellent knowledge of 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.
• Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and 271.
• Experience with EPIC user and provider record provisioning, including the development of role-based access, security classes, and user profiles
• 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 in Epic Resolute product implementation and deployment
• Hands on experience with Epic Hospital Billing and Ambulatory
• Full knowledge of application interoperability configurations and managed the implementation tasks of HIE clinical applications.
• 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 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrolment hence analysing and documenting related business processes
• Experience with Epic Healthcare Information Systems
• Conducted user interviews, gathered requirements, and analysed the requirements.
• Trained thousands of medical providers w/ ten member team on HIE software and insurance proprietary software Managed 1500 medical provider accounts including group practices, large health systems and hospitals
• Worked with the business team to collect the business requirements, security and service level requirements and documented them.
• Analysed set behaviour and contribution to business performance, critical business metrics & tracking underlying business trends using Business Objects.
• Working with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects
• Participated in the logical and physical design sessions and developed design documents.
• Designed new process flows for the existing system as well as for the enhanced system.
• Conducted and lead status report meetings with the business and the IT team on a weekly basis.
• Manage Scope and change throughout the life cycle of the product.
• Performed collection, coding, and assessment and reporting of adverse event data using ARISg.
• Worked in the ARISg Implementation of the EHR-Pharmacy Module.
• Supported integrating EDI batch processing and real-time EDI
• Recommend tactic to implement HIPAA 4010 (EDI X12 837,834,278,270) in the new System
• Worked on Electronic health record system as a CRM web based application.
• Working Experience in Electronic Submissions in standard format E2B.
• Knowledge of regulatory issues including State, Federal, AABB, CAP, CLIA, and JCAHO

Environment: Windows 7, MS Project, Microsoft Visio, SQL, Data Warehouse, BI, BO, EPIC, HL7 and Business Objects