SUMMARY:

• Over 7+ years of IT experience as a Business/Systems Analyst with Management expertise in Software Development Life Cycle (SDLC) and Business Process Re - engineering. Extensive experience in working as a IT Consultant (Contractor) with Reporting, Analytics, Data Mining, and Documenting Business Requirement (BR), Functional Requirement (FR), System Use Case (SUC), Gap Analysis (Source &Target Data Models) and Data Mapping Specification.
• Experience in FACETS Member, Provider and Claim Modules. Involved in FACETS Configuration/Customization, Reporting, Analysis and Enhancements. Familiar with Mainframe System and COBOL Language.
• Experience with CALIBER RM, Rational Requisite Pro and Clear Quest, and uploaded Business Requirement (BR), Functional Requirement (FR), and System Use Case (SUC).
• Extensive experience in the development, implementation and integration strategies towards a team oriented environment, utilizing quantitative and qualitative analytical skills. With ease in communicating/converting clients vague/non-technical requirements into precise/concise representation to the team.
• Experience in developing detailed Functional Specification (FS) through JAD sessions, interviews, on site meetings with business users & development team.
• Documented Business Requirement (BR), Functional Requirement (FR), Non-functional Requirement, System Use Case (SUC) and Data Mapping Specification and work through various review with internal and development team.
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile& Waterfall life cycle. Proven Strength in Creating guidelines and templates for designing & developing Siebel CRM applications.
• Experience in interviewing Business users & SME providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• Test Case writing (manual/automated test cases) and Conducting Tests (Integration testing, Regression testing), Black Box/White Box testing, UAT (User Acceptance Testing).
• Analysis & Design (Use Case, Sequence and Activity diagrams).
• Exceptional knowledge in testing phases with state HIX projects.
• Writing Manuals (System guides, training material for business users and Deployment guides).
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users.
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with data analysis, data mapping and dimensional modeling experience in decision support systems (data marts) using Star Schema.
• Work experience in data warehousing projects dealing with ETL (Extraction, Transformation & Load) using Oracle.
• Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Experience with HIPAA compliance (4010 & 5010) and Healthcare systems.
• Experience with Medicare, Medicaid, Medigap/Medsupp & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Experience with health care Systems: FACETS, Medicare Part A, B, C & D.

TECHNICAL SKILLS:

Methodologies: Agile, SDLC, RUP

Project Management: Microsoft Project, Microsoft Office

Microsoft Office Suite: MS-Word, MS-Excel, MS-One Note, MS-Power Point, MS- Outlook, MS-Access

Modeling Tools: Rational Rose, Microsoft Visio

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

Version Control Systems: Rational Clear Case

Testing Tools: Rational Enterprise Suite, Test Director, Win Runner

Languages: XML, UML, HTML

Databases: Oracle, IBM DB2

SQL Tools: TOAD

Operating Systems: Windows Family

Reporting Tools: IBM Cognos

Requirement Tools: Rational Requisite Pro, CALIBER RM

PROFESSIONAL EXPERIENCE:

Confidential, Chicago, IL

EDI Analyst

Responsibilities:

• Coordinated in All Plan Call Presentations and attended work through review with Internal and Development team.
• Created All Plan Call Presentations Template and uploaded in National Program SharePoint.
• Created Presentations on various ITS enhancements and assembled/compiled in Power Point for different Plan to have a review.
• Experience with HIPAA 4010 EDI gateway healthcare transactions like 270, 271, 276, 277, 837, 835, 834, 820, and 278.Knowledge of HIX (Health Insurance Exchange), HIPAA 5010 transaction set.
• Attended work through meeting with the various Plan people and documented Questions and Answers related to All Plan Call Presentations ITS enhancements and uploaded in National Program SharePoint.
• Documented Business Requirement and Functional Requirement, and uploaded in Rational Requisite Pro.
• Updated Use Cases using Balsamiq Mockups tools, and a detailed project plan with emphasis on deliverables.
• Documented Functional Specifications and System Use Cases for various ITS enhancements and attended work through review with Internal and Development team.
• Created and updated Functional Specifications and System Use Cases for various List Management System (LMS) enhancements and attended work through review with technical team.
• Monitored Change Requests and documented requirements, integrating them with Use Cases.
• Updated User Manual, Data dictionary and Meta Data.
• Created the Encounters in Epic Health care for HIX members and Medicare cost claims for Execution
• Worked as a liaison between the product development, technology and internal business units.
• Assisted QA team in testing phase by creating Test Plans and Test Cases documents.
• Worked with Testing Team and Supported in their Test Strategy, Test Plan, Test Cases, and creation of Test Scenario.
• Worked on Mainframe Systems and researched on various Plans related claims.

Environment: Agile, Mainframes, Rational Requisite Pro, Rational Clear Quest, Rational Clear Case, MS Office Suite, MS Visio, MS SharePoint, Balsamiq Mockups.

Confidential, Newark, NJ

Business Analyst/ EDI Analyst

Responsibilities:

• Participated in gathering user requirements, developing functional and non-functional requirements.
• Involved in Creating Technical Requirement Documents and Data Mapping Documents.
• Worked with Developer and Supported in Developing TDD (Technical Design Document) from TRD (Technical Requirement Document). Participate in Integrated Meetings as technical expert to ensure reconciliation across product lines while representing Health and Welfare for specific projects.
• Defined validations to be built into application in line with the functional requirements.
• Developed the Test cases and Run the claims for Professional billing claims for HIX members.
• Involved in JAD Session with SME, Business Users and Developing Teams so as to retrieve detail requirements. Utilized corporation developed Agile SDLC methodology. Used Scrum Work Pro and Microsoft Office software to perform required job functions. Followed Agile (XP) Methodology for the release. Elicited requirements for creating new web-portal and for establishing interface connections between Epic EMR and existing systems analyzed and segregated them into high level and low level User requirements and documented existing processes. Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS). Aligned company requirements to comply with CRM software.
• Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business Requirement Document (BRD). Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Designed and implemented Business Continuity Plan and analyzed critically the outcomes with technical leads to avoid any catastrophic risks. Analyze business requirements and segregated them into Use Cases. Created Use case diagrams, activity diagrams, Sequence Diagrams, and OOD using Rational Rose according to UML methodology thus defining the Data Process Models.
• Hands on experience on numerous Healthcare domains and knowledge of HIPAA, EDI (834 and 837) and HIX (Health Insurance Exchange)
• Developed various business cases and test cases in the process design phase of every iteration to carry out Cost-Benefit analysis at early stages, and generating the gap analysis report, risk assessment report. Extensively worked to develop Mapping, Business Rules design and testing of EDI 837 (Health Care Claims Transaction), 997 (Functional Acknowledgment), 277 (Unsolicited Claim Status), 835(Remittance Advice) for both Institutional and Professional claim.
• Recommended corrective actions, if necessary, along with the progress against Development/Action Plan routinely to the Project Manager.
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM). Coordination of numerous project initiatives including: system conversion and integration of a behavioral health acquisition, preparation of numerous RFP responses, other system initiatives related to case management, provider management, eligibility management, claims processing, and prior authorizations.
• Worked on Excel to create Pivot chart for reporting purpose.
• Attending meeting with QA Lead and Team to reviewing the HIX documentation.
• Worked with Facets Architects to get in-depth knowledge on Providers life cycle and how can Members and Claims get affected with Providers Network setups.
• Did Reconciliation of Data on Providers back-end table to gauge the quality and enhance quality of existing entities.
• Involved in using ETL tool (Extraction, Transformation & Load) known as Informatica Power Centre 9.
• Worked on IBM DB2 Database and extensively used SQL tool known as TOAD for DB2.
• Extensively used IBM Cognos for the Reporting purpose.
• Assisted QA Team in designing the Test Cases, and collecting the Test Metrics, writing Test Plans, Test Cases.
• Extensive Support in Developing Test Plans, Test Cases, and Expected Results, and coordinated the tests with the QA team to verify implementation of all features.

Environment: Agile, SQL Tool-TOAD for DB2,IBM DB2,ETL Tool-Informatica Power Centre 9,IBM Cognos, IBM Lotus Notes, Same time, Unix &Linux, Windows Applications, MS Office Suite-MS Outlook, MS Link, MS-Visio, MS Access, HP QTP, HP Quality Center.

Confidential, Denver, CO

Business Analyst/ EDI Analyst

Responsibilities:

• Gathering Functional Requirements by conducting JAD sessions with Technical Leads, SME, Business Users and Developing Team.
• Involved in the entire life cycle of the project starting with the user requirements, building the Object models for the functional areas, designing the Class diagrams, Sequence diagrams, Activity diagrams, components using Rational Rose. Establish documentation for Agile methodology for implementation with a very water-fall-centric development team.
• Generated FRD (Functional Requirement Document) from BRD (Business Requirement Document) and Uploaded Requirements into CALIBER RM.
• Worked with Web Services and both the MCFH, MYC Portal People & identified Presentation Layer Web Services for each Elements (Fields) displaying in the Portal.
• Mapped both the MCFH and MYC Portal fields and identified new functionality for Facets Customer. Worked with Operational team and End users to ensure the quality of data to help them get agreements from new providers.
• Worked with Users to make sure Claims get Adjudicated correctly for the new providers added into the Network.
• Involved in data mapping of EDI Transactions, creating work flow and activity and use case diagrams. Created validation documentations for the claim process.
• Manage budget and implement market plan initiatives that generate the greatest ROI
• Created Mapping Spreadsheet where MCFH Portal Fields are mapped with Presentation Layer Web Services to Stored Procedure and finally to Data Sources.
• Documented Mapping Processing Diagram and Created General MCFH Architecture and Data Flow Diagram.
• Worked with Testing Team and Supported in their Test Strategy, Test Plan, Test Cases, and creation of Test Scenario.

Environment: Agile, Borland Caliber RM, Business Objects, Unix & Linux, Windows Applications, MS Office Suite-MS Outlook, MS-Visio, MS Access, SQL Tool-Toad for Oracle 9, 10&11g,ORACLE, ETL Tool- Informatica Power Centre 9, Erwin, Toad Data Modeler 4.1,Toad for Data Analysts 3.0,IBM Lotus Sametime, Facets Data Dictionary 4.71, HP QTP, HP Quality Center.