SUMMARY:

• Around 5 years of professional experience as a Business Analyst Healthcare and Insurance Industry with an understanding and ability to work independently and in cross functional teams.
• Comprehensive understanding of healthcare domain focusing on enrollment, benefits, billing, A/R, pricing, groups or demographics area.
• Extensive experience in Software Development Cycle (SDLC), SCRUM application design, development, system testing and quality control methodologies such as Waterfall, Agile & RUP.
• Proficient in creating BRD (Business requirement Document), TRD (Technical Requirement Document), FSD (Functional Specification Document) and UAT Documents, Use Case Narrative & Use Case Diagram.
• Comprehensive understanding of HIPAA Standards (4010 & 5010), EDI (837 I/P/D, 834, 835, 277/278) and Compliance issues, Medicare, Medicaid, ICD9 & ICD10.
• Proven track record of creating and transforming business requirement into functional requirements and non - functional requirements.
• Well familiar in Claim Processing in Healthcare Industry with wide knowledge of various standards including X 12, Accredited Standard Committee (ASC) and American National standard Institutes (ANSI).
• Detailed knowledge of claim adjudication process within a healthcare payer and interacting with different hospitals.
• Experienced in JAD (Joint Applications Development), RAD (Rapid Application development) and JRP (Joint Requirement Planning Sessions).
• Exceptional presentation skills including verbal and written skills, and flexibility in adapting to new relevant information and changes.
• Extensive experience in data mapping, data modeling, data analysis artifacts and documentations.

TECHNICAL SKILLS:

Functional: Business Analysis

Domain/Industry: Healthcare, Pharmaceutical

Operating System: Windows XP,2007,WindowsNT/ 2000/2005/2008

Application Software: MS Project, MS Office Suite

Methodologies: RUP, UML, Waterfall, Agile

Requirements Management Tools: Rational Rose, Requisite Pro

Databases: Oracle, MS Access, SQL Server 2005/2008,DB2

Process Modeling: MS Visio 2003/2007/2010

Testing Tools: QTP

Programming Language: SQL

PROFESSIONAL EXPERIENCE:

Confidential, McLean, VA

EDI Analyst

Responsibilities:

• Modified and used Project Templates to gather the requirements and carry on the project.
• Facilitated the requirement gathering work sessions with stakeholders, SME’s and Business owners to understand and in corporate the potential requirements in the BRD.
• Coordinated the project team for JAD and BRD Sessions.
• Functional experience and sound knowledge of the management tools involved in the new MMIS (Medicaid Management Information system)
• Performed QA Analysis and coordinated System testing, Regression testing and UAT for several claim types and test scenarios.
• Compared and validated 5010 system test results with 4010 results for the same test scenarios.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, information needs and insured that critical requirements are not missed.
• Coordinated activities between business unit and technical staff, developed new methods, policies, and procedures to meet the business needs.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.
• Prepared Functional Design Specifications (FRS) employing Use case scenarios, sequence diagrams, DFDs and class diagrams.
• Identified and clearly defined functional issues and supported IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.
• Documented the Requirement Traceability Matrix for tracing the Test Cases and requirements.
• Documented and assisted the QA Team with the Test Plan.
• Developed Data Conversion Strategy using ETL functions for converting data from the existing site to the new site.
• Assisted Project Manager to complete the project approval process.

Confidential

Eligibility Technical Business Analyst

Responsibilities:

• Responsible for gaining a good understanding of user needs and accurately representing them in a well-documented software functional specifications document
• Gathered system requirements, interacted with the users, designers and developers, Project Manager and QA Team to get a better understanding of the processes workflow
• Followed a structured approach to organize requirements into logical groupings such as requirements for Customer, Client, Group, Member, Prescriber, Pharmacy, and Reporting to ensure critical requirements were not missed
• Created Process Documentation. Identified Use Cases from the requirement, created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams
• Analyzed and optimized the process, created System Requirement Document and managed requirements using Rational Requisite Pro
• Worked with project teams to create Software Requirement Specifications (SRS), Software Design Documents (SDD), user interface design
• Developed and pruned the artifact repository and templates to conform the RUP standards
• Drew Data Flow Diagrams and Process Flow Diagrams for the Claim Adjudication module
• Worked on 4010 HIPPA EDI Transactions, 837 medical claims, 835 Electronic remittances 270/271Elegibility inquiry and response, ICD 9 Codes
• Identified system rules and built a rule based application that automated fine-grained, variable decisions used for Claim Adjudication
• Generated Test Plans and Test Specifications as per systems requirements
• Conducted manual and automated testing at various phases of the project development
• Prepared test data for positive and negative test scenarios as per application specifications and application requirements and wrote test plans
• Performed manual testing for Integration, Build Verification, and System testing
• Performed UAT and Production Data Analysis for different client’s records also the Pre-edit report and given feedback to clients
• Involved in Proc setup/ Proc update and change for each of the client as the request in process or directly in the main frame called Rumba systems
• Review and analysis the test file of different layout of 1000 bytes, 1500 bytes, 950 layout, PDP Enhanced layout 1400 bytes for the Process of Production in Rumba systems
• Involved in HDR/TRL code decode and Member level premium CDE/DCDE (Code decode) request process, Group ID Code Decode request.

Confidential, Trenton, NJ

Business System Analyst

Responsibilities:

• Performed Requirement Gathering & Analysis by actively soliciting, analyzing and negotiating customer requirements and prepared the requirements specification document for the application using Microsoft Word.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Strong experience on Centers for Medicare and Medicaid Services (CMS)
• Managed Electronic Document Management System (EDMS) for automating and Regulatory document repositories for submissions to the FDA.
• Designed and developed project document templates based on SDLC methodology
• Conducted Business Requirements meets to identify and document business requirements. Perform analysis on project scope parameters (gap analysis, cost /benefit etc.)
• Interacted with the Development team to help write technical specifications to describe Functional Requirement Documents (FRD), Business Requirement Documents (BRD), design specifications and module specifications.
• Prepared data flow diagrams using MS Visio for better clarity, ensure documented process and flows using Visio
• Analyzed application requirements with UML process modeling (Rational Rose) and documented Dialogue application. Used Agile/Scrum Development methodology throughout Project Life Cycle
• Developed UML Use Case model for the application using MS Visio and assigned to prepare the detailed Work flow diagram based on the proposed enhancement for the system.
• Organized meetings to discuss outstanding issues with QA and developers highly involved in user acceptance testing.
• Met with client groups to determine user requirements and utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• Conducted JADs with the development/testing/business team and various stakeholders to fasten the project definition process.
• Analyzed business requirements and segregated them into high level and low level Use Case, activity diagrams/State Chart Diagrams, using Rational Rose according to UML methodology.
• Documented the business requirements using Rational Requisite Pro.
• Developed standard documentation package (Requirements, Specification, Design, Operations, and Quality Testing Plans).
• Gathered the information regarding the medical claims.
• Aided the team in completing the medical claim process by creating functional specifications.
• Understood and articulated business requirements by conducting user interviews and then converted requirements into technical specifications.
• Wrote test cases and test scripts for the User testing.
• Trained and educated field personnel on how to use various tools.