SUMMARY:

• Experienced Senior Business Analyst with over 7 years of proven skills in requirement gathering, interacting with developers, documenting various business processes, coordinating various projects contributing 3 - Years of experience in Medicare D in region of Healthcare Industries.
• Experienced in interfacing with stakeholders and senior management with excellent communication and interpersonal skills.
• Extensive experience working in all stages of system development Life Cycle. Extensive experience leading, facilitating conducting Joint Application Development (JAD) sessions among user community, stake holders and technical management, creating project plans and schedules and managing changes.
• Also, Analysed and synthesized results from Joint Application Development (JAD), proposed alternative tasks and transformed those into Business Requirement Document (BRD).
• Worked with Six Sigma methodology.
• Experience in for requirements gathering, analysis, design in Rapid Application Development (RAD) sessions to converge early toward a design acceptable to the customer and feasible for the developers.
• Experience in using methodologies such as UML (Unified Modelling Language), OOAD (Object Oriented Analysis and Design) and APM (Agile Project Management).
• Experience in Rational Unified Process (RUP), Rational Requisite Pro, Rational Clear Quest, and Microsoft Project.
• Experience using Rational Rose and MS Visio for business process modelling and designing data flow diagrams (DFD).
• Experience in conducting GAP analysis, User Acceptance Testing (UAT), SWOT analysis, Cost Benefit analysis, ROI Analysis and Requirement Traceability Matrix (RTM)
• Preparing graphical depictions of use cases including State Diagrams, Activity Diagrams, Sequence Diagrams, Use Case Diagrams, Component-Based Diagrams, Collateral Diagrams, including the Business Workflow Chart.
• Very good understanding of Relational Database, Object Oriented Programming, Data Modelling, Data Mapping and Data-warehousing.
• Expertise in writing Requirements, Technical Specs, Test Plans and Test Cases.
• Prepared Functional Specification Documents, AS-IS and TO-BE workflows.
• Strong skills performing data analysis, impact analysis, risks analysis, writing test cases for User Acceptance Testing. Gathered Functional and Data Requirements, analysed workflows and created Use Cases, Requirement Specifications, Report Specifications, Data Requirements, Data Mappings and Data Flow Diagrams.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Experience in Rational Rose & HP Quality Center
• Experienced working in Medicare and Medicaid projects.
• Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules such as EDI 837,270,271,276,277,834,835.
• Proficient inICD-9-CM and ICD -10-CM coding and claims processing.
• Experienced in all phases of the Software Development Life Cycle(SDLC), Rational unified process (RUP) and SCRUM methodology.
• Managed a Test Director environment for the test team. This includes additions to all forms in the TestDirector application (i.e. Defects, Test Plan, Test Lab and Requirements) and provides server maintenance when needed.
• Broad Knowledge in reviewing Test Procedures, creating Test plans and detailed test plans for UAT, Test scenario, defining Test cases, both System & Integration and executed many test cases Test Data reviewing and maintaining and executing detailed Test scripts for UAT, analyzing bugs, interacting with team members in fixing errors and User Acceptance Testing (UAT) and also assisted in post Production support. Worked on Black box and White box Testing.
• Experience in leading eBusiness development.
• Experience in Data Mining and analysis
• Extensive expertise in databases like Oracle, SQL.
• Thorough knowledge in Requirement analysis, Planning, Scheduling & Tracking projects.
• Worked extensively on B2B applications and B2C applications in transaction processing and E-commerce applications.
• Concrete understanding of Business Requirement gathering, Business Process flow, Business Process Modelling and Analysis, design documentation.
• Strong problem solving and analytical skills with in-depth understanding of system development methodologies, techniques and tools.
• Work with the development team to provide an environment ready for testers and end-users.
• Facilitated test plan/test case walk-thru s for the Business and Development teams to obtain feedback and/or approval sign-off.
• Excellent organizational, interpersonal, communications, teamworkand leadership skills with proven skill to interact across multiple levels of organization.

TECHNICAL SKILLS:

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

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

Databases: MS SQL, Oracle, MS Access

Test Tools: Test Director, QualityCenter, Quick Test Pro (QTP), Win Runner, HP QualityCenter

Other Tools: Visio, Front Office, Rational Rose, Rational Requisite Pro, Software Modeler, Team Test, Doors, PROLOG, Clearcase, Clear quest, Win Runner, Load Runner, Web Sphere, Microsoft Office 2010 ( Project, Word, Excel PowerPoint, Access, Visio)

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

PROFESSIONAL EXPERIENCE:

Confidential, MI

Sr. Business Systems Analyst

Responsibilities:

• Locate the 837 transactions and reports in the file that are in error and validate the data in the transactions. Dealt with the 837 and 835 ANSI X12 transaction understanding loops segments, elements and structure.
• Experience with AGILE Tool and worked with Six Sigma methodology.
• Experienced with HIPAA - 4010/5010 standards
• Monitor Medicare Part D PBM contract including, but not limited to, rebate amounts, claim pricing and benefits, formulary coverage/tiering application and contractual performance measures. Performance measures include validation of claim adjudication accuracy from both a pricing and benefit perspective. Participate in User Acceptance Testing to ensure system corrections are accurate.
• Experience in Rational Rose & HP Quality Centre
• Establish and conduct monitoring activities centered on key CMS audit findings and best practices including, but not limited to, formulary administration, point of sale edits, coverage, and claim reject reports.
• Experience in leading eBusiness development
• Provide internal departments with monitoring and audit support of Medicare Part D claims to ensure CMS compliance. Provide the necessary support to internal departments during CMS audits to document ongoing monitoring activities.
• Participate in and/or lead cross departmental workgroups.
• Extract pharmacy claims, benefit and eligibility data for studies. Gather any necessary enrollment, formulary, pricing, benefit and trend information from internal departments and the PBM.
• Knowledge of pharmacy data (claims, fees, eligibility, benefits, formulary) and statistical analyses
• Experienced with EDI files 835, 270/271, 276/277 file formats
• Extensively participated in verification of EDI file formats against Standards
• Experienced with HIPAA 4010/5010 standards
• Experienced with EDI files 834,835,270/271, 276/277 file formats
• Extensively participated in verification of EDI file formats against Standards
• Enhanced or developed new documentation of current business process flow and definition of future EDI business information flow.
• General process improvement input by attending conference calls and partner visits.
• Responsible for managing relationships with the business units as well as interacting with software vendors and consultants for development and support.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Gathered accurate and relevant incident information and Documented problems for escalation
• Developed and maintained documentation of all technical and procedural changes affecting the Specialist s area of responsibility.
• EDI healthcare experience working with implementation guides, TR3s
• Hands on experience with the 837 and 835 ANSI X12 transaction understanding loops segments, elements and structure is a must
• Used Validator Self Testing Tool to accepts claims from the Trading Partner, further monitored errors from 4010 to 5010
• Expertise in EDDI: Environment Data Compression settings to see what is set for the Output Data, validating 999s and 835s
• Worked on hand with Service Center Tool: this is used to update the records of clearing houses, vendors and submitters
• Worked with WTX mainframe for comparison of 4010 Reports with 5010 reports( 277CA) and transactions (277) and reject reports
• Mapping 4010 and 5010 differences
• Ability to read and interpret 997/999 acknowledgments
• Ability to read and interpret 277CA Reports and Transactions acknowledgments
• Ability to read and interpret 835 responses
• Coordinated the setup of new trading partners, including planning, project management, testing, documentation, and implementation. Developed and maintained functional specifications for new / existing applications needed to maintain/enhance EDI processing and address the requirements of new trading partners. Participate in transaction analysis and mapping needs, system / interface analysis, and work with programmers to implement changes as needed. Ensure that regulatory transactions and security standards have been met.
• Excellent Analytical skills verbal and written communication skills, individuals will be interacting with external trading partners and management.
• Proficient with Microsoft Office

Confidential, Saint Petersburg, Florida

Business Systems Analyst

Responsibilities:

• Implemented an integrated RUP solution with complete line of traceability for all the artifacts of web development projects
• Worked with Six Sigma methodology.
• Responsible for designing future state processes for HIPAA 5010 transaction processing EDI s 837 and 835.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between HIPAA 4010 and 5010.
• KnowledgeofICD - 9-CM and ICD -10-CM coding and claims processing.
• Involved in the creation and maintenance of the Workflow plans and artifacts
• Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models
• Experience with AGILE Tool and methodology
• Worked in Irise.
• Serve as subject matter expert with respect to the annual benefit changes and rules associated with the Medicare Part D program
• Knowledge of pharmacy data (claims, fees, eligibility, benefits, formulary) and statistical analyses
• Conducted SWOT Analysis for better market understanding and fool proof project implementation
• Experience in Rational Rose & HP Quality Centre
• Documented Requirement Traceability Matrix(RTM) for requirement elicitation and linkup to deliverables
• Experience with Claims Platforms NASCO
• Worked with the individual sub-project managers to translate these into PRDs (Product Requirement Documents) for the development teams
• Worked with XML format and being able to read XML files and use XMP parsing tools
• Examined, analyzed and model Test plans, Use Case Model cases & Test procedures based on RUP methodology
• Experience in leading eBusiness development
• Designed and developed Quality Assurance standard and processes to all levels of project team
• Performed Gap analysis for the modules in production, conducted feasibility study and performed impact analysis for proposed enhancements
• Verified the functional aspect as per the Business Process and validated the interfaces with the other systems and data conversion from the existing system
• Involved in walkthroughs and meetings with development team to discuss related issues
• Used Rational Rose to visually determine the proper structure, key elements and optimal design for database and to aid efficient creation of tables, stored procedures
• Critically evaluated the information gathered from multiple sources during requirement gathering and analysis and responsible for tracking, tracing and managing requirements using Rational Requisite
• Experience in Data Mining and analysis.
• Used MS Project for various planning and budgeting activities.
• Performed UAT and loggedtest results according to the test plans using TestDirector
• Wrote clear, concise detailed System Requirements Specification(SRS) documents and user documentation in accordance to guidelines and standards of a level where developers can interpret, design and develop the application with minimum guidance

Technical Environment: Microsoft Office( MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access),Rational Requisite, RUP, XML, VB.NET, Oracle, RUP, UML, SQL, Test Director.

Confidential, Wilmington, California

Business Analyst

Responsibilities:

• Coordinated with the stakeholders and project key personnel to gather functional and non - functional requirements during JAD sessions.
• Studied the existing business process and created AS-IS workflow to illustrate the existing system.
• Recorded requirements in the Requirement Traceability Matrix (RTM) defining each technical requirement in detail from areas like: main hardware, application software, networks, servers, internet and desktop configuration.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Experience with AGILE Tool and methodology
• Worked in Irise.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS. Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Assisting the project manager in creating the business case and project plan.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Actively analyzed current business processes (Claims, Recipient eligibility and enrollment etc.) and worked with management to improve and implement enterprise solutions to ensure compliance
• Work with business representatives to understand data marts requirements and priorities and ensure that IT works is appropriately aligned.
• Responsible for creating business work flows and processes and creating management reports based on the analysis.
• Experience with Claims Platforms NASCO
• Experience in Rational Rose & HP Quality Centre
• Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, Sequence Diagram, Collaboration Diagram that include Functional and Non-Functional specifications to hand off to development teams.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting
• Defects and bug testing by using Rational Clear-Quest, Configuration management and Version control with Clear-Case.

Technical Environment: Microsoft Office(MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access), RUP, MS Project, ANSI X12- EDI UML, Rational Requisite Pro, MS Word, Visio, SQL, MS Excel, Mercury Quality Center.

Confidential, Parsippany, New Jersey

Business Analyst

Responsibilities:

• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Involved in the creation of the Mockups and Use Cases for MACD quotes and Orders using MS Visio.
• Documented business requirements, and communicated these requirements with the development team for design and implementation of business solutions.
• Worked with Business Analysis team to prepare a detailed Business Requirement Document.
• Analyzed Business Requirements to develop Functional and detail Design Specifications of the application.
• Conducted Requirement Gathering Sessions with the stakeholders.
• Interacted with the project team to help define the Business and System Objectives, confirmation of scope, identify constraints and the measures of success for the system to be developed.
• Conducted the JAD sessions, daily meetings, brainstorming sessions to solve the problems and enhance the workflow.
• Assisted in building a Business analysis process model using Rational Rose and Visio.
• Gathered Functional Requirements from users and the management. Coordinated all the requirements in team based environment.
• Acted as liaison between the senior management and different teams with effective presentations.
• Experience in Rational Rose & HP Quality Centre
• Monitored change requests and documented requirements, integrating them with Use Clear Cases.
• Incorporated stakeholder feedback throughout project lifecycle to ensure project quality and customer satisfaction.
• Did Technical documentation for the project using tools like Visio, Word, etc.
• Used MS Project for managing schedules, resources and collaboration.

Technical Environment: Microsoft Office( MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access),RUP, MS Project, Toad, Visio, Oracle, HTML, Test Director, Rational Rose, UML 2.0, MS Project

Confidential, Denver, CO

Business Analyst

Responsibilities:

• Gathered Business Requirements, analyzed data/workflows, and defined the scope.
• Developed prototype of a new mobile information processing application. Met with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Technical Requirement Specification.
• Facilitated collection of Functional Requirements from system users, and prepared Business Requirement documents and have applied the RUP modelthroughout the entire development and testing process.
• Involved in development of Business and Technical Requirements in preparation of Design and Functional Specifications for Business Needs and Processes.
• Worked closely with Business users to determine the workflow of the product
• Performed walkthroughs of the prototype with end users to better understand user needs.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams.
• Prepared Logical Process and Data Models that contained set of diagrams and supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the data elements to analyze and document Business Data Requirements. Coordinated work plan between project manager and client.
• Worked closely with the offshore team to convey Technical and Functional specifications.
• Coordinated with the offshore UI designer to prepare the prototype for the application.

Technical Environment: Microsoft Office, Tomcat, JBoss, Windows XP, Business Objects, ToadVisio, Oracle, HTML

Confidential, Lemoyne, PA

Business Analyst

Responsibilities:

• Gathered Business Requirements, analyzed data/workflows, and defined the scope
• Met with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Technical Requirement Specification
• Facilitated collection of Functional Requirements from system users, and prepared Business Requirement documents
• Responsible for claim adjudication like Medicare claims, professional claim, institutional claims.
• Applied the RUP model throughout the entire development and testing process.
• Involved in development of Business and Technical Requirements in preparation of Design and Functional Specifications for Business Needs and Processes.
• Worked closely with Business users to determine the workflow of the product.
• Performed walkthroughs of the prototype with end users to better understand user needs.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams
• Prepared Logical Process and Data Models that contained set of diagrams and supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the data elements to analyze and document Business Data Requirements.

Technical Environment: Microsoft Office, Windows XP, Toad, SQL, JBo, Business ObjectsToad, Visio, Oracle, HTML, XML