SUMMARY:

• Have 5 yrs of working experience as a Healthcare Business Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling.
• Experienced working on HIPAA implementation guides relate to Claim Testing and Medical Billing
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
• Familiar with HIPAA Standards and Compliance issues, HIPAA Privacy policy, requirements gathering in compliance with HIPAA standard.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum, RUP (Rational Unified Process) and Software Testing Life Cycle (STLC).
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document (BRD) and Functional Requirement Specifications (FRS) document.
• Facilitated one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
• Experienced in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Involved in maintaining performing GAPanalysis, Requirement Analysis, Document Analysis.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277). Thorough knowledge about Facets.
• Proven ability to support multiple complex projects under tight deadlines, often with competing priorities.

TECHNICAL SKILLS:

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management Tools: Rational Requisite Pro, Rational Rose, MS Visio, HP ALM

Operating Systems: Windows 2000/7/XP, DOS

Languages/Standards: SQL, HIPPA 4010/5010, ICD

Methodologies: Agile, Waterfall

PROFESSIONAL EXPERIENCE:

Confidential, Raleigh, NC

Business Analyst

Responsibilities:

• Responsible for participating in the design sessions, reporting on project progress and identifying potential risks and issues.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems.
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277, 837/835 transactions.
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Defined and documented the vision and scope of the project.
• Gathered requirements, developed Process Model and detailed Business Policies.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Involved in writing and implementation of the test plan, and various test cases for UAT.
• Analyzed EDI transactions in XML and X12 responses.
• 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. Assisted in developing Project Proposal, Business Case.
• Analysis of existing data requirements using SQL to document functional requirements from high level User Stories.
• Extensively involved in creating and entering dummy data to test the functionality of various modules of EDW and how the modules integrated with the EDW database and the Facets database in the backend.
• Conducted Data analysis using SQL on the backend databases for producing mapping documentation and transformation rules for developers
• Configure Providers (Individual, Group and IPAs) per Provider Change Management application (PCMA) load information and utilize Contracts module to identify appropriate contracts and networks for non/credentialed providers using legacy fee tables crosswalks, signed contracts, NPI Registry, EDI 835 & 837 Claim image (1500 & UB04)
• Design and maintain all EDI maps to ensure compliance to all business requirements and analyze all EDI implementations and recommend improvements to processes and coordinate with trading partners to resolve all issues effectively.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277, 837/835 transactions.
• Worked on Health care Eligibility and Benefit, Claim Status transactions 270/271, 276/277, 835, 837 based on the HIPAA compliant ANSI X12 version 5010
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.

Environment: HIPAA EDI X12, 834, 835, 837, ICD10, MS SharePoint, MS Project, Windows XP, HTML, XML, CSS, SQL, SQL Server, MS Office and Agile framework

Confidential, Durham, NC

Business Systems Analyst

Responsibilities:

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements.
• Designed a claim processing system for the healthcare management client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms (ICD codes), and treatment (CPT).
• Responsible for gathering the functional requirements for the health benefit claims receiving and processing system.
• Conducted requirement gathering sessions with the purpose of creating and defining the Business Requirement Document (BRD) and the Functional Requirement Document (FRD) using Rational Requisite Pro.
• Involved in Requirement Scoping and analyzing high priority requirement. Conducted sign - off meetings with IT teams to lock down the requirements.
• Created high-level Use Cases from Business Requirements and created UML diagrams like Use Case and Activity diagrams using MS-Visio.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives with each other, resolve any issues and come to an agreement quickly.
• Tracked stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Involved with the following list of HIPPA-EDI Transaction Code sets: 837, 835, 270/271,277/275 and 276/277
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Involved with the Quality Assurance Team to develop and design test plan and test cases.
• Executed test cases and test scripts for manual and automation testing. Defects are raised in the HP Quality Center/HP ALM for logging, tracking and reporting bugs in the application.
• Conducted User Acceptance Testing (UAT) of the application with the QA team.
• Performed testing of the health benefit claims receiving and processing system to ensure that the system adheres to project standards, performance criteria, and functional specifications.

Environment: MS Office Tools, Windows XP, Facets, MS Project, SharePoint 2007, MS-PowerPoint, SQL, Agile framework

Confidential, Jacksonville, MO

Business Analyst

Responsibilities:

• Prepared scope of the project and developed new business process along with process mapping and user task analysis. I also evaluated documentation analysis and business process analysis to identify the problem with existing system and find out new and advance way to develop business process, which was able to make the process more accurate.
• Garnered information and knowledge on ICD 9-10 and HIPAA 4010/5010 as well as Developed the transaction process more accurate and real time regarding 837 including HIPAA Government Regulatory Compliance and also integrated the system with HL7 process.
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Conducted JAD session with business side to identify and gathered high level requirements and evaluated the priority level on the basis of meeting discussions and comments on requirements.
• Developed a vision plan that defined the primary goals and objectives of the project. Analyze user stories and segregated them into high level and low level.
• Utilized corporation developed Agile SDLC methodology used scrum work pro and Microsoft office software to perform required job functions.
• Derive the required data by SQLs and export into Excel files
• Designed and defined User Interface requirements and visual patterns by creating wire frames and screen mockups.
• Strong understanding about user interface (UI) and user experience (UX) design principles and users centered methodology.
• Developed user guides, provides user training, and supports the user in development of work processes. • Supported UAT to evaluate the system performance and also developed system plan to quality center, review design, view test cases.
• Generated reports for quality metrics using SQL Queries.
• Maintained Change and Traceability Matrix throughout the project keeping track of the scope, timelines and budget of the project as well as collaborated with development team to determine the security access and it's tracking to ensure privacy of End users.
• Used SQL for querying underlying database tables.
• Wrote various SQL queries to create, update, modify tables, create reports and retrieve information from the database.
• Creating application specific test plans and test case to support User Acceptance Testing (UAT)
• Provided weekly status updates to project stakeholders on the progress of project development activities.
• Worked with developing team to create advance claim submission process for Medicare and Medicaid patients as well as EDI transaction such as: 837 (P, I, D), 835, and 276/277.

Environment: SQL Server, .NET, Windows XP, Informatica, Facets, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, Java, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML.