SUMMARY:

• 10+ plus years of solid experience in Business Analysis with IT as a BA/QA on health domain and digital marketing.
• Extensive exposure to financial industry in regard to capital market (Personal, Business and commercial services).
• Highly accomplished professional with a proven track record of leading complex, cross - functional and result-oriented.
• Served as a liaison between the business sponsor, vendors, and the IT infrastructure during the analysis phase of the project.
• Extensive knowledge on different Medicare part D Letters, TRR / TRC codes.
• 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 with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience in writing Medicare and Medicaid requirements as per the Centers for Medicare and Medicaid Services (CMS) guidelines.
• Excellent Knowledge in Healthcare Medicare Part D implementation using Market Prominence.
• Good Knowledge in CMS Policies, Procedures and CMS files.
• Extensive experience gathering, defining, business requirements (BRD) translating them into technical specifications and functional requirements (FRS) documents for the inbound and outbound EDI processes for HIPAA compliant files.
• Experience in EDI automated first-pass claim adjudication, requiring through understanding of claim processing, both front and backend operation.
• Worked with HIPAA/ Electronic Data Interchange (EDI) transaction sets -- 270/271,835, 276/277 and 837 transactions.
• Facilitated JAD (Joint Application Design) sessions.
• Involved in data mapping and data model documentation for 835,837 EDI transactions for 4010A1 to 5010 conversion. Proficient in all the phases of SDLC which includes analysis, design, development and deployment.
• Designed procedures for data conversion and migration across different system.
• Functioned as the bridge between functional business units and IT.
• Participated in sprint planning, daily scrums meeting, testing, and sprint reviews.
• Experience working closely with SME in various areas of the business and leverage experience to identify areas of product and process improvements.
• Expertise in implementing full Software Development Life Cycle (Agile-Scrum, Rational Unified Process, Waterfall SDLC methodologies)
• Writing user stories; expertise in defining Business Process Analysis, Business Process Mapping, Requirements Elicitation, Data Analysis and Process Modeling.
• Experience in Feasibility studies, SWOT Analysis, Gap Analysis, and Risk analysis Interpersonal, collaboration, and problem-solving skills.
• Experience using Rational Unified Process (RUP), MS Office Suite (including Excel, Word Access, power point and Outlook), and MS SharePoint to manage project tasks.
• Experience to lead on the rollouts of organization suite of products to ensure adoption and continued customer success.
• Well versed in Front-end, Functional, Integration, Regression and System Testing of Web Testing and Functional Testing.
• Experience to interface directly with senior business stakeholders and users to gather business requirements Functional Requirement Document (FRD), Software/Technical Requirement Specification (SRS) across the deliverables of a project.
• Expertise in preparing use case documents and utilized MS Visio to create UML diagrams including use case, activity, sequence and class diagrams to extract business process flows and workflows, thereby assisting development and quality assurance teams in understanding the requirements.
• Expertise in facilitating Joint Application Development (JAD) sessions, Requirements Workshop sessions, conducting user interviews and acting as a liaison between the clients, Managers, Consultants, End users, Developers, QA and all other stake holders of the project.
• Expertise in Microsoft tools: MS Visio,share point,MS Office (PowerPoint, MS Word, MS Excel, Access)
• Strong Presentation, Analytical, Communication (Written and Verbal) skills, Interpersonal Skills and ability to work independently and work with cross-functional teams and with different business units.

TECHNICAL SKILLS:

Systems/Architectures: Web, VB Client/Server, Main Frame, Windows

Languages: SQL, JAVA, HTML, C++, C, R

Databases: SQL*LIMS, Oracle, MS Access, MySQL

Test Tools: Test Director, Quality Center, Quick Test Pro (QTP), Win Runner, HP Quality CenterOther Tools: Visio, Front Office, Rational Rose, Rational Requisite Pro, Software Modeler, Rational Unified Process (RUP), Agile,(Jira) Waterfall, Rapid Application Development (RAD) Hadoop, R, Tableau, SharePoint

Standard Skills: HIPAA, SOX, ISO, Six Sigma, CMM, FACETS

PROFESSIONAL EXPERIENCE:

Confidential

EDI/ Specialist

Responsibilities:

• Followed CMS Policies, Procedures and CMS files.
• Gathering, defining, business requirements (BRD) translating them into technical specifications and functional requirements (FRS) documents for the inbound and outbound EDI processes for HIPAA compliant files.
• Experience in EDI automated first-pass claim adjudication, requiring through understanding of claim processing, both front and backend operation.
• Worked with HIPAA/ Electronic Data Interchange (EDI) transaction sets -- 270/271,835, 276/277.
• Involved in data mapping and data model documentation for 835,837 EDI transactions for 4010A1 to 5010 conversion. Proficient in all the phases of SDLC which includes analysis, design, development
• Functioned as the bridge between functional business units and IT.
• Participated in sprint planning, daily scrums meeting, testing, and sprint reviews.

Confidential, Detroit, MI

EDI/ Specialist

Responsibilities:

• Create Functional Specification Documents based on Business Requirement document.
• Conduct weekly reviews with the client.
• Designed work-flows for the Core Capitation Processes.
• Created wire-frames for UI details as part of functional specification documents.
• Communicated with various teams such as IBM, HP, NASCO, BCBSMA and Horizon BCBS.
• Worked on Membership, Provider and Benefit File modules.
• Extensively used MS Visio to create various Sequence-Flow or Work-Flow diagrams for existing and projected Decision.
• Developed use cases, project plans and helped manage scope.
• Assisted in building a business analysis process model using Rational Rose and Visio. Produced Visual models for the application using Rational Rose.
• Developed BRD (business Requirement document), FRD (functional requirement document), Test cases, Production Release plan/back out plan.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and Smart draw using UML.
• Followed SDLC, which included requirements specifications, design, analysis and testing. Followed RUP methodology with Agile/Extreme Programming and using Rational Test Suite for various phases of RUP.
• Provided technical Expertise on the use of Rational Clear Case and Requisite pro, which were used for Data archiving and Requirements Management.

Environment: HIPAA, JAD, ICD 10, XML, ANSI X12 5010,MS VISIO, SDLC, RTM, UAT, Rational Requisite Pro, MERCATOR, MS Office, MS Project, Rational rose, Test Director, DB2, and TOAD.

Confidential, Fairfax, VA

Business Analyst

Responsibilities:

• Provide commercial /therapeutic research information for weekly review.
• Assist in the set-up of the new hospital web portal and document new business processes to support training roll out.
• Generated test cases in Claims Analyzer Editor Professional to ensure unification with CPT-4 and ICD-9 codes
• Work with DHHS and Department of Mental Health Services to ensure all BPM requirements related to: Computerized physician order entry (CPOE), clinical data repository (CDR), Electronic Health Record, Clinical Research and Pharmacy have been captured
• Used IBM Web Sphere 6.1 application server for application development and production.
• Involved in gap analysis and implementation of HIPAA 5010, ICD10 and Claim Validations
• Involved in loading the data into oracle Applications
• Implement SharePoint for team collaboration and Document Management.
• Work with Project Manager to document informatics and software needs (2 existing hospitals) that will serve as final processes for new hospital.
• Conducted one on one telephonic and face to face interview with the end users (the healthcare professionals) of the doctor-centric portal to research their areas of interest so as to be able to identify key challenges, define project scope deliverables and ultimately developing the application features for their benefit.
• Obtained Data requirements, identified data sources, determined the content of data fields and created Data Mapping Documents and performed Data Extraction and Data Compilation using SQL queries.
• Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared Business Requirement Documents (BRD) using Rational Requisite Pro.
• Created screen-mockups using iRise to review the requirements and provide feedback on the screen design. Also, used Microsoft Paint to create ad-hoc screen mock-up to review with the users.
• Involved in the full HIPAA compliance lifecycle from gap analysis, mapping, and implementation and testing for processing of Medicaid Claims.
• Used Rational Unified Process (RUP) and Rational Rose to create UML Models to design and manage requirements using Rational Requisite Pro throughout the full lifecycle of the project
• Responsible for designing test scripts for testing of Claims in Development, Integration and production environment.
• Used Unified Modeling Language (UML) for process modeling and use cases.
• Analyzed CMS comparison documentation highlighting changes of 5010 format and ICD10 diagnosis and procedure codes.
• Prepared Business Requirement Documents (BRD’s) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Performed Data Analysis of existing data through SQL and experience with EDI & ETL.
• Involved in the full HIPAA compliance lifecycle from gap analysis, mapping, and implementation and testing for processing of Medicaid Claims.
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.

Environment: EDI ANSI X12/HIPAA, MEDISTAT, Rational Requisite Pro, MERCATOR, XML, MS Office, MS Project, MS Visio, Rational rose, Test Director, DB2, TOAD, Cobol, IBM Web Sphere, Windows NT/XP.