SUMMARY:

• Over 9 years of Business Analysis experience with in - depth knowledge of Software Development Life Cycle (SDLC) and business processes in health care sector.
• Experience in conversion of HIPAA X12 4010 codes to X12 5010 codes, ICD 9 codes to ICD 10 codes, FACETS and Business Process Reengineering in Health Care Sector.
• Strong understanding of Medicaid Management Information System (MMIS), Patient Protection and Affordable Care Act (PPACA), Health Level Seven International standards (HL7), Health Care Reform, and Claims EDI.
• Working experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS/RAPS).
• Specialized experience in healthcare insurance domain including Medicare, Medicaid, PBM, Procedural and Diagnostic codes and Claims Process. Profound experience with HIPPA X12 EDI transaction codes such as 270/271 (inquire/response health care benefits and eligibility), 276/277 (Claim-status), 278 (Transmitting health care service information), 834 (Benefit-enrollment), 820/835 (Payment/remittance advice), 837 P/I/D (Health care claim).
• Proficient in Requirement Management, including gathering, documentation, analysis, detailing and tracking requirements, Quality Assurance, Testing and End user support working as Business Analyst mainly in Healthcare sector.
• Experienced in documenting requirement using Unified Modeling Language (Use Case and Activity Diagrams). Also building business Process Flow, Context Diagrams, Sequence Diagram, Activity Diagrams, Class Diagrams using Rational tools and Microsoft Visio.
• Good knowledge of Revenue Cycle Management, Cash Posting, NPI, NDC, DRG, CPT, NCPDP codes and NSF formats for interfaces & images to clearinghouses/trading partners applications.
• Strong understanding of various PMO techniques used in SDLC such as Rational Unified Process (RUP), Waterfall, Agile and SCRUM with hands on experience in each of them.
• Experienced in interacting with business users to identify their needs, gathering requirements, developing detailed functional specs through JAD sessions, interviews, on site meetings and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project.
• Extensive hands on experience in creating RTM, Defect Status Report, Change Request Form, Test Plan and Collaboration Diagram and designing User Interfaces (GUI) and wireframes.
• Strong Knowledge with Iterative approach for Software Development as per Rational Unified Process (RUP). Involved in inception, elaboration, construction & transition phases using rational tools like Requisite Pro, Clear Case, and Clear Quest during various phases of RUP.
• Experienced in SWOT Analysis, Gap Analysis, Impact Analysis, Risk Analysis, and Project Planning. Excellent analytical skills in understanding the business process (AS-IS and TO-BE).
• Exceptional Problem Solving and Sound Decision Making capabilities, along with ability to manage and resolve increasingly complex situations through Root Cause Analysis.
• Extensive knowledge of RDBMS, Web and SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Good knowledge of NASCO system, SCHIP/CHIP, CMS, HMO, PPO, POS and EMTALA.
• Experienced in writing Test Case (manual/automated test cases), Conducting Integration/Regression testing, Black Box/White Box testing, UAT (User Acceptance Testing).
• Strong Subject Matter expertise in Credit Card Industry, Retail/Investment and SOX.
• Possess a detail-oriented nature with excellent communication, interpersonal and organizational skills. Recognized for being a valued team player with ability to multi-task.
• Strong command in converting client’s non-technical requirements to precise technical representation to the team. Experienced in dealing with cross-functional team environment.

TECHNICAL SKILLS:

Business Skills: Business Process Analysis & Design, Gap Analysis, Impact Analysis, JAD/JRP Sessions Requirement Gathering, and Use Case Modeling

Methodologies: Agile, RUP, SDLC, SCRUM and Waterfall

Languages: C, SQL, HTML5, UML, XML, Informatics Power Center

Change Management Tools: Clear Quest, Test Director and Rational Requisite Pro

Version Control Systems: Rational Clear Case

Testing Tools: HP Quality Center, Rational Enterprise Suite

Defect tracking tools: Rational Clear Quest and Test Director

Databases and RDBMS: DB2, Oracle, SQL Server, Sybase MS Access

Operating Systems: Windows Vista/7/8, Mac, MS-DOS, UNIX

Project management tools: MS Office Suite, MS SharePoint, MS Project, MS FrontPage

Modeling Tools: Rational Rose, Microsoft Visio

PROFESSIONAL EXPERIENCE:

Confidential, Durham, NC

Business System Analyst

Responsibilities:

• Translated and communicated requirements between the business users, Truven’s ETL team and the technical SAS team.
• Conducted multiple requirement gathering sessions with the State and individual vendors.
• Developed Requirement Analysis Document (RAD) and Technical Design Document (TDD) for each extract project and ICD-10 efforts.
• Conducted JAD sessions with team members from different functional areas (Data Integration Programmers, Database Architects, ETL and Data Acquisition, Project Managers and Developers)
• Assisted the Project Managers with project planning and initiation efforts.
• Conducted System Integration Testing (SIT) and User Acceptance Testing (UAT) for each extract file delivered to the client.
• Documented and conveyed the test results to the end client and assisted with user queries and downstream updates
• Assisted the ETL team in Data Acquisition from NCTracks and Loading data to Staging tables and Data Warehouse.
• Produced Reconciliation Reports and field level record count validations and data validations for each extract file using SQL Developer and DataStage tools.
• Conducted impact analysis for existing tables in Data Warehouse (DW) impacted by ICD-10 changes.
• Coordinated with the ETL and DBA teams to update/replace existing DW tables in order to make them ICD-10 compliant.
• Assisted the product support team with handling User Stories, Transition Requests (TR) and Service Requests from the client.
• Used Rally to capture and track User Stories, Transition Requests (TR), Test results, Project and Release Status.
• Developed Process Flow Diagrams and Work Flow Diagrams in MS Visio.
• Assisted with customer activities including but not limited to user support, query design, data quality development implementation and support of the SAS EBI solution.
• Performed several data analysis and reporting tasks using skills in statistics and database management.
• Review claims transactions and work on Truven’s Data Warehouse R&A and SAS solutions.

Environment: Rally, MS Project, MS Office, MS Access, MS Visio, Adobe Dreamweaver, Power Designer, PLSQL Developer, SAS

Confidential, Bismarck, ND

Business Systems Analyst/Systems Designer

Responsibilities:

• Documented business and system requirements including both program-level and user-level documentation, make use case models and other analysis documents for development efforts.
• Produced business process models, data models (BPM), site maps, wire frames, web page prototypes and Graphical User Interfaces (GUI) for state Medicaid client and worker portals using tools like Sybase Power Designer, Microsoft Visio, Adobe Dreamweaver etc.
• Created several use-case diagrams and scenarios in Rational Jazz and Clear Quest to describe the relationship between use cases, system and actors.
• Performed GAP analysis to assess “AS-IS” and “TO-BE” scenarios and created process flow diagrams for all such scenarios using MS Visio.
• Conducted JAD sessions with business units and stakeholders to define project scope, identify business flow and determine whether any current or proposed systems are impacted by the new development efforts.
• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Prepared and maintained requirements traceability matrix (RTM) throughout the project lifecycle.
• Used Blaze rules engine to automate business policies and procedures in an agile environment.
• Developed design concepts for applications, including operational features, user interface and interactions with other equipment using Business Service Documents (BSD) provided by CMS.
• Developed webpage prototypes and UI mockups for North Dakota Department of Human Services Medicaid client portal and worker portal to demonstrate compliance with stakeholder requirements and specifications and provide solutions to complex and challenging issues.
• Produced Business Design Specifications (BDS) and Technical Design Specifications (TDS) to convey business and functional requirements gathered during analysis, to development team.
• Guided QA and Developer in identifying defects, and understanding Technical Specification Documents and Mapping Documents.
• Utilized Agile Methodology to configure and develop process, standards and procedures.
• Created and updated workflow diagrams, UML diagrams, process models, activity diagrams and use cases to demonstrate original stakeholder requirements as well as in corporate design changes occurring later in the process.
• Designed the view and processing for several client portal and worker portal webpages for North Dakota Eligibility System.
• Defined and documented the process of receiving and processing the healthcare applications sent to the State by FFM as well as the application submitted to the State directly through State hosted portals.
• Researched and documented various scenarios to demonstrate the similarities and differences between Assessment Model and Determination Model for States relying on FFMs for coordinating Medicaid and CHIP Eligibility determinations with the State.
• Reviewed and modified the Physical Data Model (PDM) and Conceptual Data Model (CDM) for client database with database team.
• Created detailed Design Specification documents and facilitated design sessions with stakeholder as well as peer reviews.
• Reviewed architecture diagrams with the team and suggested and documented updates for improvement of current Entity Relationship Diagrams (ERD).
• Created, maintained and resolved Problem Logs focusing on various problems related User Acceptance Testing (UAT), System Test and Contingency Testing.
• Participated in ongoing pursuit for implementing Health Insurance Exchange (HIX) by mandate deadline.
• Maintained documents for change request and implemented procedures for testing changes.
• Analyzed several Service Requests (SR) submitted by business or end user throughout the life of the project and incorporated them into the system being built.
• Identified all risks associated with the project, gave suggestions for mitigating the impact the identified risk posed to the business and documented lessons learned.

Environment: MS Project, MS Office, MS Access, MS Visio, Adobe Dreamweaver, Power Designer, PLSQL Developer.

Confidential, Seattle, WA

Business Analyst

Responsibilities:

• Assisted in building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, Medical policy waves.
• Conducted working sessions to gather and document detailed and high level business requirements for different business units impacted by ICD 10 such as EDI Claims Intake, FACETS, Utilization Management, Case management and Provider Reimbursement/Provider Payment.
• Involved in managing the risk adjustment process for Medicare advantage plans throughout the RAPS to EDPS (Encounter Data Processing System) transition.
• Designed wire frames, screen mock-ups and Graphical User Interfaces (GUI) for client’s worker portal.
• Prepared use cases and data flow diagrams in Rational Jazz, MS Vizio and MS Word to analyze the impact of ICD 10 diagnosis codes embedded in different systems and applications.
• Contacted SME’s to collect and finalize all system and business process requirements for incorporating changes to existing Medicaid Management Information System (MMIS).
• Prepared and maintained requirements traceability matrix (RTM) throughout the project lifecycle.
• Worked closely with project manager and team leads to coordinate resources and document cost estimates throughout the project.
• Worked with PBMs to monitor prescription safety across several pharmacy networks and reviewed formularies. Worked on pharmacy claims processing and facilitated reconciliation.
• Coordinated with Business Project Teams, Business Owner, Application Vendor, Payers and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements.
• Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements.
• Performed Accounts Receivable Data entry with specific involvement in Cash Posting and closely interacted with Revenue Cycle Management team.
• Worked closely on 837 I/P transaction code for Health care claims and was involved in Validation of HIPAA for 270/271 (health care benefits and eligibility), 276/277 (Claims Status), 835 (Payment/Remittance advice), 834 (Benefits Enrollment) EDI transactions.
• Designed and developed Business Rules document about the Claim Component and HIPPA.
• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non-functional requirements.
• Performed the Gap analyses of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams. Specifications, Documentation and Construction of systems heavily relied on UML.
• Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results were properly interpreted and managed to ensure Payer acceptance of the files.
• Tracked all required resolutions that were identified as needed from Vendors or Payers based on testing results.
• Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.

Environment: MS Project, MS Office, Rational Requisite Pro, Clear Case, Clear Quest, Jazz.

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Involved in Business Process Redesign and its documentation.
• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Performed Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Worked with subject matter experts to update existing Medicaid Management Information System (MMIS) in order to ensure HIPPA compliance.
• Conducted JAD sessions with business units and stakeholders to define project scope, identify business flow and determine whether any current or proposed systems are impacted by the new development efforts.
• Involved in validation and submission of RAPS (Risk Adjustment Processing System) data to CMS (Centers for Medicare and Medicaid Services) and correction of rejected RAPS data.
• Interacted with PBMs and NCPDP throughout the process of negotiating and processing prescriptions.
• Attended daily SCRUM and guided QA and Developer regarding the defects, Technical Specification Documents and Mapping Documents.
• Worked with Cash Posting to ensure immediate adjustment to the customer's Accounts Receivable balance.
• Utilized Agile Methodology to configure and develop process, standards and procedures.
• Involved in claim adjudication process of facets application.
• Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management system
• Coordinated the upgrade of Transaction Sets 837 P/I (Health care claim Professional/Institutional), 820/835 (Payment/Remittance advice) and 834 (Benefit Enrollment) to make it HIPAA compliant.
• Took action to mitigate claim denial through a complete analysis of the application “Claims Scrubber” to ensure 277CA (Claims Acknowledgement) accepted claims would not result in an increase in denials at the payer adjudication level.
• Performed on the EDI 834; loading files to Facets through MMS (Membership maintenance sub-system).
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEM. Also performed gap analysis between ICD 9 and ICD 10.
• Performed gap analysis and impact analysis for the Facets up gradation system.
• Developed the business requirements and use cases for Facets batch processes; automating the billing entity and commission process.
• Performed as a facilitator for Testing Efforts and New Requirements between the Healthcare Company and its various Vendors.
• Successfully elaborated the Current process and proposed process for the projects in the organization. Work actively for completing High Priority Tasks on time.

Environment: Facets, Agile, Requisite Pro, MS Access, MS Visio, MS office, Clear Case, Clear Quest, Quality Center, SQL.

Confidential, Cleveland, OH

Business Analyst

Responsibilities:

• Involved in HIPAA/EDI Medical Claims Analysis, Design, Implementation and Documentation.
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Gathered requirements and prepared business requirement documents (BRD).
• Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models.
• Written multiple Use Cases for multiple transactions include 837I (Health care claim Institutional), 835 (Payment/Remittance advice), 276/277 (Claims status), 270/271(inquire/response health care eligibility and benefits; both inbound and outbound).
• Maintained Requirement Traceability Matrix (RTM).
• Use Case development and UML modeling using modeling tools like Rational Rose/MS Visio.
• Presented the nursing outcomes to C-Level executives in Gentiva Nursing and Data Management group using Crystal Reports XI.
• Created product documentation, printed user manual and training materials.
• Defined Use cases from requirements and helped convert them into software specifications.
• Analyzed business needs, created and developed new functionality to meet real time data integration that facilitated decision-making.
• Developed queries using SQL to automate the weekly and monthly “Meds Update Reports” and FCO reports.
• Coordinated Regression Testing and created test scenarios for User Acceptance Testing (UAT).
• Maintained documents for change request and implemented procedures for testing changes.
• Deployed, in-house MS Access Database for constructing data tables, queries and reports, for Project and Program review.
• Coordinated cross functional task forces to remove impediments.

Environment: Rational Rose, Rational ClearCase, RUP, MS Visio, MS Project 2000, UML, HTML, TestDirector, SQL Server, MS Office (Word, Excel, PowerPoint), Load Runner.

Confidential, Atlanta, GA

Business Analyst

Responsibilities:

• Gathered requirements and prepared business requirement documents (BRD). Responsible for translating BRD into functional specifications and test plans.
• Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Developed and maintained all operational and technical flows using Visio and Power point. Aided in workflow analysis and process design.
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models.
• Defined Use cases from requirements and helped convert them into software specifications
• Analyze business requirements from Black Box testing perspective, business process and system architecture/design.
• Involved in HIPAA/EDI Medical Claims Analysis and Documentation.
• Written multiple Use Cases for multiple transactions including 837I, 837P, 835, 276, 277, 270, 271(both inbound and outbound).
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Maintained Requirement Traceability Matrix (RTM).
• Performed Regression Testing and test scenarios for User Acceptance Testing (UAT).
• Maintained documents for change request and implemented procedures for testing changes.

Environment: Rational Rose, MS Office Suite, Windows NT/XP, SAP, Business Objects, J2EE, EJB2.0, JMS, SQL, Web Services, Tag Libraries, UML, CSS, MQ Series, WSAD, Web sphere 5.1

Confidential, Dallas, TX

Business Analyst

Responsibilities:

• Determined user/business/functional requirements. Created vision, scope, and use case documents; business process models, use case diagrams, activity diagrams, and state chart diagrams.
• Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures.
• Performed GAP and Risk analysis of existing system and evaluated benefits of new system.
• Conducted Joint Application Development (JAD) sessions with stakeholders throughout SDLC to resolve open issues.
• Collected, documented, and managed business requirements using Requisite Pro.
• Validated technical designs created by IT developers against functional specifications. Coordinated work plans between project manager and client using MS Project.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams.
• Created documentation for training and Help Desk teams.
• Implemented and customized Goldmine SQL Server 2000 CRM and QuickBooks Pro on a Windows 2000 Server.
• Models were programmed using MS Excel Visual Basic for Applications and are linked to databases using MS Query and Open Database Connectivity (ODBC) database drivers.
• These models include forecasting, pipeline management, product information, budgeting, completed and scheduled work day activities, lead management and more.
• Analyzed and assessed the clients systems and business processes.
• Assisted in building a business analysis process model using Rational Rose and Visio.
• Performed requirement analysis, developed all the use cases and workflows.
• Worked with QA team to design test plan and test cases for User Acceptance Testing (UAT).
• Developed Use cases for all the scenarios involving interaction with the enrollment system. Also assisted Testing Team in coming up with appropriate test cases.

Environment: OO Modeling, Rational RequisitePro, Rational Rose, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.

Confidential, Fargo, ND

Business Analyst

Responsibilities:

• Constructed and incorporated Logical Process and Data Models containing diagrams and essential business elements and detailed definitions in the Business Data Requirements.
• Conducted group-effort in documenting the Pre-Business Requirements documentation for current AS-IS and future TO-BE scenarios to assist new Project Managers in processes and methodologies orientation.
• Assisted project and program managers in setting timelines and milestones, vendor interaction, and reported on project status to business unit, on a daily and monthly basis and produced information architecture deliverables for project.
• Used MS Project to assign tasks and responsibilities to the team and track milestones for the project.
• Participated in the entire life cycle of projects related with initial situational gap analysis, change management, operation design procedures and overall project scoping.
• Participated in JAD sessions, providing constructive feedback on process flows, business and technical requirements and aligning existing reports to concurrent AS-IS reports being generated live.
• Performed GAP Analysis to figure out what we have and what we ought to have to be at better-off. Created use cases using UML.
• Facilitated documentation and information to the intra- corporate E-Reports portal for archiving and compliance purposes in a joint-effort lead by Project Managers, complying with the SOX regulations and legal requirements.
• Assisted the technical team in understanding and developing the appropriate functionality.

Environment: Rational RequisitePro, Rational Rose, RUP, UML, MS Project, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.