SUMMARY:

• Facilitator between Business Systems and Information Technology with over 7 years of extensive Business Analyst skills - Understanding of Software Development Life Cycle (SDLC), Rational Unified Process (RUP), Agile/Scrum methodology, Unified Modeling Language (UML), Object Oriented Analysis and Design Concepts (OOAD), Business Process Re-engineering (BPR), Test Lifecycle, Data Modeling.
• Experience in writing Business Requirements Documents (BRD), System Requirement Document (SRD), Use Case Specifications, Functional Specifications, and Technical Specifications across the Deliverables of a project.
• Good experience in Relationship Database Management System (RDBM).
• Experience in handling Change Management and Release Management.
• Extensive Experience in UML and Process modeling using Use Case Diagrams, Activity Diagrams and Sequence Diagrams.
• Good experience in conducting Joint Application Development (JAD) sessions through interviews and workshops with subject matter experts and business users.
• Good experience with Rational Rose, Rational Requite Pro, Rational Clear Quest, Rational Clear Case, MS Project, MS Visio, Crystal Reports.
• Experienced in conducting GAP analysis, User Acceptance Testing (UAT), Risk Analysis and mitigation plan, Cost benefit analysis and ROI analysis.
• Well versed with Medicaid Management Information Systems (MMIS), National Provider Identification (NPI) and familiar with Patient Protection and Affordable Care Act (PPACA).
• Experienced in various MS Windows platforms, OS, Office Suite, etc.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 277, 999, 997 and ICD9-ICD10.
• Extensive knowledge of Medical Management Information Systems (MMIS), Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process
• Strong knowledge of Health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI), Implementation and knowledge of HIPAA code sets, ICD-9, ICD-10 coding, HL7, HMO, PPO.
• Presented several documents and Use Cases for multiple transactions and worked with ANSI X12 5010 and ANSI X12 4010 including the standards for medical transactions like 837I, 837P, 835, 834, 277, 270, 271(both inbound and outbound) transactions for ongoing industry projects.
• Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans. 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.
• Experience with Business Process Management.
• A motivated, committed, quick learning, detail-oriented team player with good communication, analytical, leadership, interpersonal and problem-solving skills.
• Understanding of pharmacy benefit management.

PROFESSIONAL EXPERIENCE:

Confidential

Healthcare Business Analyst

Responsibilities:

• Confidential of Tennessee is an independent licensee of Confidential Association. It's a part of 41 independent locally operated companies called plans. Each Plan is community based, working closely with local hospitals and physicians to assure its customers receive excellent and affordable care tailored to their needs. I worked as a Business Analyst on the Health care application Dashboard. The project was to upgrade the existing Dashboard phase from phase 1 to 2 for claims and benefits. I was responsible for Requirement gathering and design, including process mapping and gap analysis and writing use case on the extended application which supports Dashboard and involved in writing Business rules based on 270/271 transactions and HIPAA Standards.
• Identified and validated business rules and data elements.
• Gathered Requirement from the Client to fulfill the Application need for FACET Implementation
• Created 837(P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837(P, I, D), 834, 835, 270, and 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 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.
• Worked with Facets software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPPA transactions and facilitate the administration of HIPAA privacy rights.
• 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 eligibility.
• Review vendor files for any errors, missing segments, and for missing data on X12 file. Ensure file has complete data before encounter can be submitted to Medicare and Florida Medicaid.
• 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.
• Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifecs.
• Tracked the change requests.
• Utilized Ramp Manager Application from Florida Medicaid to check X12 files for any error before submitting to Florida Medicaid.
• Daily and weekly status reporting to senior management.

Confidential

Business Analyst

Responsibilities:

• The project aimed at fixing the Medicaid / Medicare membership to synchronize with State and Vendor. It also included adding some error prompts to adjudication system and automating reports.
• Also, another project undertaken for the same client was the implementation of HIPAA 5010 and migration of ICD 9 to ICD 10.
• Gathered requirements by coordinating with external vendor, and internal team.
• Analyzed Gap Analysis of the HIPAA 4010 and HIPAA 5010 processes to identify and validate requirements.
• Coordinated JAD sessions with all the stakeholders to understand the impact of HIPAA 5010 on the existing system.
• Gathered requirements for "Front End" and for "Core Adjudication System" by conducting meetings and brainstorming sessions with end users and Subject Matter Experts (SMEs) and documented them using Requirement Traceability Matrix and later exporting them to HP Quality Center.
• Prepared Business Requirement Documents (BRDs) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Gathered requirements for ICD 10 transition.
• Organized requirements into High level Use Cases and Low level Use Case Specifications and modeled them into UC, Activity and Sequence Diagrams using MS Visio.
• Assisted the QA personnel in the creation of Test Cases using HP Quality Center.
• Defined and analyzed test cases, test scripts, bugs, interacted with QA/ development teams in fixing errors and conducted User Acceptance Test (UAT).
• Coordinated and prioritized outstanding defects and enhancement/system requests based on business requirements, allowing sufficient time frame to ensure accuracy and consider deadlines
• Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifecs
• Tracked the change requests.
• Maintained and tracked the project plan using MS Project.
• Daily and weekly status reporting to senior management.

Confidential

Healthcare Business System Analyst

Responsibilities:

• Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
• Involved extensively in Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 837 and proprietary format files and Reports development.
• Analyze medical and claim data from various EMR/EHR, PDS (Practical Data Solutions) and PMS (practice management software) systems.
• Worked to configure following EDI transaction 277, 837I, P &D, 834.
• Designed and documented new EMR functionality and associated work/data flows.
• Working with HIPAA, EDI transaction sets 837, 835, 834, 820, 270, 271, 276, 277, 278, EMR and EHR.
• Adjudicated medical claims for correct pricing to administer payment to medical providers.
• Identified gaps between standard FACETS functions and client specific requirements to write requirements for FACETS extensions.
• Implemented Healthcare system including enterprise Electronic Medical Records (EMR) software.
• Worked in Facets online modules such as Billing, Provider, Claims and Membership modules.
• Ensure all the staff and the EMR are compliant to HIPAA regulatory and compliance requirements.
• Validated various applications with Memberships of Enrollment, Cancellation, Termination, Reinstatement etc. for commercial, Medical and Billing in Facets.
• Performed Gap Analysis and created test plans for clients for conversion from data collection to EMR solution.
• Setting up appropriate network servers, tablets, printers, EDI, and PC's which are used to run and support selected EMR.
• Validated the HIPAA/EDI transactions, tested the claims processing and Adjudication (EDI 837 & EDI 835).
• Gather requirements by conducting meetings and brainstorming sessions with end users and SME and document them using Requisite Pro - the documentation tool offered by Rational.
• Used MS Access, MS Excel (Pivot tables), and SQL for data analysis and data validation.
• Undertook back end testing using SQL and wrote queries.