SUMMARY:

• Qualified professional with over 8+ years of extensive experience in the field of Sr. Business Analyst working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, enrollment, Medicare, MMIS, Medicaid, CDHP (consumer driven health plans).
• I have good experience in HIPAA, ICD9 to ICD10 experience, EDI 270/271, 834, 835, 837 for claims processing
• Experience in B2B, B2C and Ecommerce portals web application developments.
• Experienced as a Sr. Business Analyst in using the iterative software development life cycle principles of Rational Unified Process to manage, develop and test distributed client/server, internet and intranet applications on heterogeneous environments.
• Experienced with Medicare and Healthcare Insurance; as well as Medical Standards (HIPAA and HL7).
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Excellent Knowledge in Electronic Medical Record (EMR) / Electronic Health Records (EHR) modules and process flow.
• Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
• Deep knowledge of PPACA rules surrounding the Enrolment and Eligibility piece.
• Experienced in SSIS, SSAS, SQL Server Reporting Service (SSRS), Executing Queries and Running Store Procedures.
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• Experience in MITA 2.01 (Medicaid Information Technology Architecture) business and technical architecture implementation including health information Exchange HIE concepts.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Extensive experience in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from an Operational Data Store to an Enterprise Data Warehouse.
• Experience in writing Request for Proposals (RFP), Statement of Work (SOW) and Standard Operating Procedures (SOP).
• Experience with HEDIS measurements, annual reporting, medical record review and HEDIS auditing. Expert proficiency in Microsoft Excel, Access Word, PowerPoint and Visio. Knowledge of NCQA/HEDIS.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications
• Gathered and documented Non-functional requirements.
• Experienced in preparing Business Process Re-engineering Models
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Worked as a Business Analyst and UAT Tester for ICD9 to ICD10 project on the Professional Claims side.
• Strong experience using various Java frameworks & tools such as spring, Hibernate & Struts2.
• Conducting requirement gathering sessions, feasibility studies and Impact Analysis and organizing the software requirements in a structured way using Rational RequisitePro to track development.
• Exceptional computer application skills, including Epic Ambulatory and Kaleidoscope and MS office products.
• Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.
• Worked in close co-ordination with the testing team in developing test plan and test cases from functional and business requirements.
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Used Rational ClearQuest for tracking and prioritizing defects and for enhancements after base lining the requirements.
• Used Rational ClearCase for Version Control of requirement documents.
• Well versed in writing queries/Scripts for Data Analysis and QA reporting and testing.
• Good knowledge of Workflows and Content Management Tools.
• Experience in Change Management Process (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Expertise in Procurement and Management Services
• Experience in implementing Microsoft Office SharePoint.

TECHNICAL SKILLS:

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite(Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Mainframe: COBOL, DB2, JCL, CI CS, MVS

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

PROFESSIONAL EXPERIENCE:

Confidential -Topeka, KS

Sr. Healthcare Business Analyst

Responsibilities:

• Designing and developing Kansas Medicaid Account for ICD 10 (International classification of disease) changes for Benefit Plan Administration(BPA) Sub-system, Financials, Claims, Managed Care, Recipient, Prior Authorizations, EDI (Electronic Data Interchange), Reference, EDMS (Electronic Data Management System), and EPSDT(Early Periodic Screening Diagnosis and Treatment) system.
• Involved in gathering business requirements, design and development for the BPA, EPSDT, EDMS, EDI, Claims, Financials, Recipient, Prior Authorization and Managed Care modules.
• Ensured all artifacts compiled with HIPAA 5010 policies and guidelines.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Gathering requirements and preparing functional documents for Facets 4.71.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Did gap analysis for HIPAA4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
• 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.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems as well as for ICD 9 to ICD 10.
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEMs and incorporated that into a Translator Tool.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using MS Visio towards facilitating clear understanding of the business process
• Responsible for documenting and delivering user Requirement Review Document (RRD), Business Requirement Document (BRD) documents, process flow diagrams
• Responsible for reviewing the High Level Design Document (HLD) and Low Level Technical Design (LLD) for Benefit Plan Administration, Financials, Claims Managed Care, EDI, EDMS, Recipient, EPSDT subsystems
• Documented the meeting minutes about issues discussed and solutions resolved.
• Identifying and mitigating the risks, applying creativity innovation to solve complex problems; building relationships and working collaboratively; developing and communicating a vision for system; providing the thought leadership; mentoring; effective verbal/written communication; preparing and delivering effective presentation
• Created, updated and reviewed business and functional requirements. Worked closely and collaboratively with client and member of delivery to facilitate analysis and trouble shooting and closure and resolution.
• Involved in analyzing and modifying the professional, inpatient, pharmacy and dental FFS and Encounter claims processing and adjustment claim processing for ICD10 diagnosis and procedure codes.
• Involved in analyzing and processing ICD10 codes for EDI files Inpatient, Professional, pharmacy and Dental claims through 5010 X12 formats.
• Worked and supported on EDI Translators to analyze EDI files submission for Professional, Inpatient, Outpatient, pharmacy claims and dental claims Errors with ICD10 codes.
• Involved in remediating financial fund code assignments and DRGs (Diagnosis Related Group) for inpatient, professional claims, and RA(Remittance Advice) reports, pay reject reports, adjustments reports for ICD10 diagnosis and procedure codes.
• Involved in modifying the implementation of CMS416-EPSDT Annual Participation file, Health Check reports EPSDT system for ICD10 diagnosis and procedure codes.
• Involved in analyzing and processing of the benefit plan administration business rules to enforce the state policies for ICD10 diagnosis and procedure codes
• Involved in analyzing and processing of table driven benefit plan structure, recipient plan, and provider contract and reimbursement agreement business rules to process ICD10 claims to pay, deny or suspend.
• Involved in analyzing and processing of claims with prior authorization for ICD10 diagnosis and procedure codes.
• Worked on Medicaid and CHIP program requirements, including complete end to end life cycle data flow of eligibility, enrollment, claims, encounters, payment and post-payment
• Involved in analyzing and processing of managed care recipients and managed care participants (MCPs) associated with HH (Health Homes), SI (Supplemental Income) and CSP (Coordinated Service Program) plans processing.
• Involved in analyzing and modifying current system for managed care benefit enrollment process834. Involved in managed care recipients for capitation changes and delivery payments changes 820for International classification of disease ICD10 diagnosis and procedure codes
• Involved in reviewing, writing scenarios, reviewing scripts, helping data preparation, helping executing the scripts and supported the component testing, system test, model office test (MOD) and user acceptance testing (UAT)

Environment: MS project, MS Visio, Excel, Power Point, ITRACE, SharePoint, MS Visual Studio 2010, SQL, QC, HIPAA 4010/5010, FACETS 4.71, EDI 837, 835, 834, ICD 9 CM ICD 10 CM.

Confidential, Atlanta, GA

Sr. Business Analyst

Responsibilities:

• Performs detailed gap analysis between client requirements and base system design, to identify areas for potential.
• Responsible for the oversight of all operational aspects of TriZetto's Fraud, Waste & Abuse Division with a particular focus on waste and abusive billing patterns.
• Modification or enhancement related to MMIS (Medicaid Management Information System) security.
• Manages the system security and role privilege matrix requirements in MMIS System
• Serves as liaison between the customer and the development team for business analysis activities.
• Conducted Process Improvement Project for ADHD in efforts to raise our HEDIS rates.
• Manage and facilitate fraud, waste and abuse detection and prevention throughout organization.
• Design the Epic electronic medical record ADT module and customize workflows based on the requirements and expectations of the end users.
• Developed documentation system to track and monitor allegations of fraud, waste or abuse. worked with data mapping team for ICD 9 to ICD10 for forward mapping of the diagnosis and procedure codes
• Analyzed the processes in medical coding and transition from ICD 9 to ICD 10.
• Created reports to evaluate provider performance relative to patient care and associated HEDIS measures.
• Analyzed issues with EDI transactions and fixed IDOCs to be submitted into SAP for order fulfillment.
• Work with a tem to migrate remote clients to meet the EPIC Hardware requirements.
• Created lists of ICD9 - ICD10 CM/PCS codes, with reference to the usage percentile and provided to Stakeholders to determine if codes were best-fit or all possibilities.
• Key contact for handling EDI Production Support issues and handled calls from Trading Partners as well as Maxtor's various fulfillment groups.
• Timeline management of all HEDIS related data collection activities including HEDIS-related quality improvement projects.
• Review daily EDI transmission to ensure EDI is being sent and acknowledged successfully, if not then determine what is the issue and follow up to resolve
• Also support Extol Integrator EDI package and develop RPG/ILE interfaces for new trading partners.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Implemented Premenos EDI with Hertz & Delta Airlines and Xign internet EDI (Order to Pay service (XPSN) Xign Payment Services Network), with Sprint.
• Formulated system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes such as HIPAA/ EDI formats and accredited standards.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Assists with managing client expectations; provides clear, concise and timely communication and support to customers throughout the development lifecycle.
• Ensures that project deliverables conform to QA and contractual requirements and that all project standards are met
• Develops and maintains Business and Use Cases.
• Effectively applied Scrum /Agile methodologies and enforcing project standards using Rally tool.
• Planned, directed and coordinated the activities of multiple teams utilizing agile methodology best practices (Scrum). Supported product owners to maximize ROI and meet the organizations objectives through Agile. Participate in architecture and design sessions. Involved in coaching, teaching and guiding teams to adopt the Scrum methodology.
• Serves as Subject Matter Expert (SME) for the development team during construction and unit testing
• Worked on CMS (Center for Medicare and Medicaid Services) checklist, MITA, HIPPA and GAP analysis.
• Assists with the development of System Test Plan; develops system test cases, scripts and system test data.
• Identifying specific HEDIS measures for relevance and impact on quality goals for patients and practices alike.
• Participating in HEDIS performance reporting and intervention analysis.
• Map the MECT checklist requirements with different MITA business process areas.
• Uses automated testing tools where appropriate; executes system test plan; analyzes results; documents and manages defects
• Coordinates defect resolution with developers and retests resolved defects
• Develops customer deliverables, including Requirements Validation Specification documents, General System Design documents and Detailed System Design documents
• Provides on-site support of customer during implementation activities
• Provides issue resolution recommendations to project managers for each project.
• Ensure that there is regular and effective communications of issues and corrective actions between teams
• Participates in the Issue Tracking procedures, and serve as gatekeeper of the issues.
• Make customized changes to the MMIS per state guidelines and client request
• Managed security access into MMIS for clients as well as staff.
• Facilitated Behavioral Health work groups in effort to raise our HEDIS rates for Behavioral Health measures.
• Created new security reports and maintained other security reports within MMIS system
• Reporting using SQL for different Query reporting.
• Created queries within IBM Rational Clear Quest.

Environment: Rational Rose and Requisite Pro, HEDIS,MS Visio, Microsoft Office SharePoint 2007, MS Project,HIPAA,MMIS, MS Access, ICD-10 and ICD-9, AHIMA,UML,MMIS, Mainframe, SOA, COBOL, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9i.

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Participate in Systems testing and UAT followed by post production support created a workflow to distinguish between ICD-9 & ICD-10 codes in cases of overlap.
• Prepare statistical and medical quality performance reports.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) reports.
• Analyzes and resolves problems and complaints about payment of claims for Health services provided to Medicaid recipients. Prepares letter responses and answers inbound and outbound telephone inquiries from Medicaid providers.
• Configured, analyzed, and tested Epic Resolute Hospital, Home Health, and Hospice Billing applications based on end user workflows, state and federal regulations, and patient needs.
• Integrate complex Medicaid principles and policies into the Medicaid Management Information System (MMIS), requiring knowledge in areas of health systems and Medicaid information processing.
• Responsible for overall research and gathering of required documents for HEDIS project, including activities involved with the setup and conducting HEDIS Onsite Audit.
• Created, socialized and obtained approvals for three decision documents: ICD 10 Procedure Codes, Medicare, and Backward Mapping (ICD 10 - ICD 9).
• Knowledge of the entire Systems Development Life Cycle (SDLC) with experience in the design, implementation, and maintenance phases.
• Implementing process and managing food safety and quality holds.
• Planned, trained all employees, and implemented the Quality Assurance Module in SAP.
• Facilitated Project Managers and Project Leads in performing CMMI Level 5 activities.
• Interviewed product owners for requirements and acceptance criteria, and wrote Business Requirement Documents in compliance with IEEE.
• Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, Websphere and Cognos.
• Validate system performance through audits for MMIS files.
• Ensure current Edits and Audits are applicable for ICD 10 Diagnosis codes and ICD-10-Procedure Coding System (ICD-10-PCS) PCS Codes.
• Tested claims Edits and Audits to ensure that the system would recognize and accept the ICD-10 changes.
• Assist in the performance of HEDIS related duties, which include maintenance of reports and spreadsheets, gathering information specific to HEDIS measures, and verifying accuracy of reports.
• Well versed with FDA and IEEE standards for Quality Assurance.
• Designed and developed Java Batch Application and generated automated email notification using Java Mail API.
• Determine primary, secondary and tertiary coverage on accounts for Managed care and Medicaid payers.
• Collaborate with all government agencies as directed to support the fraud and abuse efforts. Effective utilization of the antifraud artificial intelligence software.
• Participated in various Healthcare presales initiative for EHR applications, HIPAA 4010-HIPAA 5010 and ICD9 - ICD10 conversions.
• Develop implementation guidelines and principles for practice-based clinical applications, including various practice management and EMR systems.
• Develop and implement change control policies and procedures for EMR template change requests.
• Worked on HL7 to provide framework to carry out transfer of electronic healthcare information.
• I assisted the Epic Resolute Hospital Billing and Epic Security team with successfully completing Phase I and Phase II of their system Go-Live.
• Conducted surveys of health plans, Medicare & HEDIS to document encounter reports.
• Create Fraud, Waste and Abuse Training to be distributed company wide.
• Responsible for the development and ongoing oversight of fraud, waste and abuse dashboards for senior leadership.
• Supported the Business Unit in obtaining higher Capability Maturity Model Integration (CMMI) level participating in a group interview representing this project.
• Ensured billing and premium collection are modified to support 820 HIPAA transactions set.
• Partnered with other functional teams to determine root-cause of quality related issues and drive corrective actions.
• Responsible for SDLC Technical Writing/Requirements Gathering.
• Created SDLC documentation for a Documentum-based document management system migration and enhancement project.
• Worked with technical teams to collect requirements and publish SDLC documents.
• Involved in requirement gathering phase (Provider, Claim components and HIPAA).
• Ensured that requirements were mapped and test cases were executed and test results were logged in Test Director and Quality Center according to Medicaid Information Technology Architecture (MITA) processes.
• Conducted sessions over MITA and practiced it. Worked over Companion guide.
• Develop technical specifications for, and analyze functions of, the MMIS and review test data.
• Document Trading Partner Migration Process Flow from HIPAA 4010A to 5010; create process flow diagrams and presentation materials; and monitor production and release events.
• Worked in mainframe environment and used SQL to query various reporting databases
• Facilitated JAD sessions for Requirement Validation and requirement gathering for the new MMIS.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Lead Business Intelligence reports development efforts by working closely with Microstrategy, Teradata, and ETL teams.
• Been a part of Architecture and modeling team and have used SOA (Service Oriented Architecture).
• Database planning and logical and physical design using MS-Access to assist the team lead.
• Worked with SQL queries using MS Access for data manipulations.
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.
• Gathered business user requirements during inception phase through JAD sessions and follow-up SME interviews and participated in project scope definition.
• Converted MS Access database to MS SQL database using MS SQL 7.0 Server Enterprise Manager. Created SQL scripts for uploading procedures.
• Knowledge of Patient Protection and Affordable Care Act (PPACA).
• Extensively involved in data modeling.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• 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.
• Meticulously assessed data from various sources and generated conceptual and logical database designs using ERwin data modeling tool.
• Manage the HEDIS project to include adherence to plan timeline, and vendor oversight for timeliness and quality.
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Analyzed trading partner specifications and created EDI mapping guidelines
• Documented the Traceability Matrix for tracing the Test Cases and requirements related to them.
• Designed and developed project document templates based on SDLC methodology

Environment: Windows 2000/XP, CCMI, Microsoft Office SharePoint 2007,IEEE,AHIMA,PPACA,MMIS, ICD-10 and ICD-9,Rational Requisite Pro, MS Office, SQL Server, SDLC, Agile, MS Project, MS FrontPage 2003, MS Access, Erwin, Mainframe, SOA, COBOL, HEDIS, EDI, Documentum 2.0.,UML.

Confidential, Nashville, TN

Business Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Part of the team developing the business use cases/system use cases using the RUP Methodology and processes for Logical Data Model and Physical data Model.
• Performed GAP analysis for ICD-9, ICD-10 and EDI 5010 X12 Message Structure with the 4010 Structure.
• Leaded the development of Business Requirements Documentation (BRD) for analysis related to the ICD-10 mandate.
• Trained in IEEE-based test fundamentals of planning, design and use of software life cycle test techniques.
• Expertise in identifying, investigating, and resolving matters of fraud, waste and abuse.
• Worked with quality team to ensure end-products met the requirements for the new Merck SDLC templates.
• Implemented NCQA's HEDIS & QM to measure performance of healthcare and service.
• Experience in an outsourced healthcare insurance operations environment and understanding of MECT and MITA.
• Part of the project team to migrate existing vendors trading EDI documents via Value Added Network (VAN) onto our FTP server to reduce operating costs.
• Met with relevant stakeholders to obtain EDI contacts for all vendors to communicate testing schedules and ensured project completion.
• Managed SDLC process using PRISM software and ITUP.
• Perform AS IS and To BE analysis for EDIFECS Standards- HIPAA 5010 Database Setup for new version releases. Documented proposed changes and coordinated development, testing and production release environments, including end-to-end testing.
• Mapped 'to-be' processes that are aligned with the MITA maturity model and the CMS certification checklist.
• Participated in an enterprise level Electronic Medical Records (EMR) system implementation.
• Create CMMI documentations (Standard, Plan, and Guideline).
• Perform SDLC end of phase and monthly CMMI Score Card audits.
• Perform end of Phase CMMI Score Card audits.
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Facilitate process for requirements validation that follows the MITA process/sub-process business model.
• Designed new database tables to meet business information needs. Designed Mapping document, which is a guideline to ETL Coding.
• Interprets business needs, tests against MMIS functionality and translates differences into System Enhancements and/or Functional Defects.
• Substantial report development experience utilizing SQL Server Reporting Services (SSRS), Cognos Impromptu, and Microsoft Excel.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Determined and reviewed of basic financial eligibility of persons applying for Medicaid benefits.
• Conducted JAD sessions and developed various strategies to distribute the work in team, dealing with huge number of documents from state to meet the deadline.
• Responsible for claim processing in MMIS.
• Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data
• As a result of the Patient Protection and Affordable Care Act (PPACA), Aetna must provide a rebate to enrollees on an annual basis.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Improvements to the Quality Management Internal Audit Program such as Auditor training, review of audit findings, increasing communication with all departments.
• Analyzed and documented ICD 10 requirements related to data elements, data exchange and data transmission.
• Involved in process modeling, conducted & Participated in Joint Application Development (JAD) sessions with System Users.
• Develop financial model to help predict effects of PPACA.
• Designed and implemented basic SQL queries for testing and report/data validation
• Assigned tasks among development team, monitored and tracked progress of project following Agile methodology.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest

Environment: Requisite Pro, Rational Rose, Agile, CMMI,SDLC,IEEE,Mainframe,PPACA,ICD-10 and ICD-9, Microsoft Office SharePoint 2010, MMIS,MITA,SOA, Erwin, COBOL, PL/SQL, HTML, Java, XML, MS Office, MS Visio, MS Access, DB2, EDI, UML.MMIS.

Confidential, Harrisburg, PA

Business Analyst

Responsibilities:

• Gather requirements by conducting one-on-one meetings and brainstorming sessions with end users and SME and document the gathered requirements.
• Responsible for detecting, correcting, and preventing Medicare and Medicaid fraud, waste, and abuse.
• Perform Gap Analysis of the processes to identify and validate requirements.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Represented the organization in an annual audit to achieve CMMI level 5 V1.2.
• Worked on the Gap Analysis by comparing the actual state and the ideal state of the SDLC process.
• Actively used project management tools to independently manage medium/large-sized projects related to system infrastructure stability and maintainability.
• Assure proper Medicaid staff addresses issues relating to policy and decisions which would impact ICDS program.
• Generate monthly and other periodic status reports for Medicaid management.
• Triaged and conducted investigations for Grievance/Potential Quality of Care Reports.
• Monitor all Affordable Care Act regulations to create client briefs and library for PPACA compliance.
• Developed fraud, waste and abuse policies and procedures to demonstrate prevention, detection and reporting of potential fraud, waste and abuse.
• Keyed Medicaid claims on Medicaid portal for adjudication. Also process claims for Medicaid adjustments via web portal.
• Implemented SDLC phases like requirement gathering, analysis, design and development and testing.
• Log and document all allegations of Fraud, Waste, and Abuse reported by Health Integrity, Office of Inspector General, Center for Medicare and Medicaid Services (CMS), beneficiaries, employees, and anonymous witnesses.
• Reported on quality management system performance, improvements and recommendations.
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Designed the Quality Management Dashboard providing Senior Management with the ability to view audit, ICAR statuses and delinquencies in real time.
• Apply UML notations and methodology in developing models that accurately represent the process workflows and clearly communicate them to the stakeholders.
• Ensuring compliance with HIPAA (transaction sets 837,270,271,276 and 277) to ensure standardization of EDI transactions.
• Facilitated and managed the integration of Quality Management Systems with SAP software critical to plant-wide communication and operations.
• Manage software remediation of 16 applications to meet government ICD-10 billing code modification mandate.
• Conduct internal and external fraud investigations.
• Designed conceptual and logical data models of Data Warehouse and tables.
• ID and document all hospital enterprise wide systems and interfaces to assess ICD-10 impacts.
• Prepare all the documents as per IEEE format including the diagrams representing the system.
• Analyzed fiscal implications related to the PPACA related policy change for the non-profit status of the organization.
• Incorporated and implemented all the HIPAA standards, Electronic Data Interchange (EDI), transaction syntax like ANSI X12, ICD-9, ICD-10 coding.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 codes.
• Authored IEEE compliant Quality Assurance Plan and Verification and Validation Plan.
• Reviewed state documents (policies, manuals, business processes, systems documents, banners, bulletins) from various divisions. Analyzed and performed quality assurance to determine areas impacted by HIPAA 5010 and ICD-10 related data.
• Mapped ICD codes and prepared final result summary documents with reports.
• Trained internal teams how to maintain the agile framework.
• Organized guest lectures and a health policy roundtable, to motivate students in the direction of health services research and PPACA related health policy programs.
• Adhered to the Capability Maturity Model Integration (CMMI) standards.
• Facilitate JAD sessions involving the management, development and user teams for clarifying requirements and facilitating better communication.
• Performed Analysis of ICD 9 Procedure and Diagnosis Codes in accordance with ICD 10-CM and ICD 10 PCS Conversion Compliances using GEM.
• Performed GAP analysis to assess "AS IS" and "TO BE" scenarios between HIPAA 4010 and HIPAA 5010 and conversions of codes from ICD 9 to ICD 10.
• Design, configuration and implementation of SaaS contracts lifecycle management solution (Selectica).
• Crated Use Case Diagrams and Activity Diagram in Rational Rose.
• Used Rational Clear Case version control system to keep track of different versions of artifacts generated within the life cycle.
• Assisted in Quality Assurance Process Management by ensuring ticket closures on time & escalating the issues to management in case for issue resolving.

Environment: Rational Rose and Requisite Pro, Microsoft Office SharePoint 2007,MS Visio, MS Project, HIPAA, MMIS, MS Access, SDLC,CMMI, UML,MMIS, Mainframe, SOA,IEEE, COBOL,PPACA, ICD-10 and ICD-9, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9i.

Confidential, Marietta, GA

Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Provides direct support for the development, sustainment, update, and maintenance of the company's Quality Management System In accordance with ISO9001: 2008 Standards.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Used the requirement attributes (priority, effort, and risk) as the basis for negotiating the inclusion of the requirement, to manage the scope of the system efficiently.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• BI architect for data warehouse tables consumed by Microstrategy and other reporting tools, utilize dimension modeling, develop table DDL and SQL script for ETL processing
• Defining Data/Attribute Modeling and ETL load required to integrate into MicroStrategy
• Used MMIS - Medicaid Management Information System for Insurance Claims Filing and patient information using MITA - Medicaid Information Technology Architecture as a platform.
• Reviewed outcome of the EDI Tests to ensure everything processed correctly according to Test Plan, if not then take action.
• Assist Medicaid staff in designing/modifying MMIS processing cycle reports.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Perform a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 utilizing the ICD-10 codes.
• Proposed strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.Facilitate HIPAA integration and applied ANSI ASC X12 standards for 837 (P, I, D), 270/271, 276/277, 278, and 835 transactions.
• Leading the enterprise initiatives like ESB (Enterprise service bus), ECM (Enterprise content management) keeping MITA architecture in perspective.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) reports.
• Implemented the entire Agile Software Development Life Cycle of application development.
• Administered all Agile/Scrum process and assisted junior staff on same.
• Managed changing requirements which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Prepared and documented System Requirements and workflows for the Content Management Application tool.
• Create technical design documentation for the data models, data flow control process, metadata management.
• All MITA business processes were reviewed and a feasibility study was conducted to integrate the EHR Provider Program business process into standard MITA business process.
• Extensively involved in the modeling and development of Reporting Data Warehousing System.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.
• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
• Develop, build and manage Reporting Services (SSRS) reports using both SSAS cube and relational database sources including distribution of reports using subscription services.
• Employed Rational Clear Quest for effective Change Management (Requirements Creep) and bug tracking during the testing lifecycle.

Environment: Rational Rose and Requisite Pro, SDLC, Microsoft Office SharePoint 2007,MS Visio, MS Project,HIPAA,MMIS, MS Access, UML,MMIS, Mainframe, SOA, COBOL, ICD-10 and ICD-9, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9i.

Confidential, Indianapolis, IN

Business Analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Created Process Work flows, Functional Specifications documents and documented system requirements.
• Working with clients to better understand their needs and present solutions using structured SDLC approach.
• Produced Initial Medicaid Information Technology Architecture (MITA) State Self-Assessment Report to support the current Medicaid Management Information System (MMIS) Replacement Project.
• Conducted JAD sessions during the client site visit to collaborating partners like Creehan (Specialty Pharmacy IT Solutions - Pittsburg USA) and Cystic Fibrosis Foundation (CFS Washington- USA).
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI).
• Documented various key elements of HIPAA compliance and made sure that they were understood by the development teams and ensured that the test cases written for the project were HIPAA complaint.
• Develops and execute testing strategies for MMIS system changes. Strong background in testing entire systems life cycle and skilled in testing various Medicaid software.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) reports.
• Experience in an outsourced healthcare insurance operations environment and understanding of MECT and MITA.
• Extensively involved in HIPAA 5010 User Acceptance Testing (UAT). Defined and maintained Test Cases for EDI transactions.
• Intricately involved in Business Process Flow development, Business Process Modeling, and ad hoc Analysis
• Interaction with the developers to report and correct bugs.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Develop, build and manage Reporting Services (SSRS) reports using both SSAS cube and relational database sources including distribution of reports using subscription services
• Developed the systems implementation project management plan with milestones and steps from procurement of vendors to project implementation and maintenance.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs. Ensured that critical requirements are not missed.
• Communicated changes to requirements promptly and precisely to all personnel involved.
• Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementatin phases of the software development life cycle.
• Analyzed and translated business requirements into system specifications.

Environment: J2EE (JSP 1.1), EJB(2.0), Servlets 2.2, JMS, Java2 (JDK 1.3),HIPAA, STRUTS,MMIS,JDBC2.0, XML, XSL, SDLC,XSLT, Rational Rose, MS Access, PL/SQL, HTML, CSS, JavaScript, Websphere4.0,Oracle 8.0, WebSphere Studio Application Developer v5.0, Win2000, Unix(AIX)