- EDI Analyst/ Business Analyst with over 7 + years of experience in Health Care domain with Claim adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
- Proficient in complete, RUP, WATERFALL and AGILE Client /server architecture providing a well - balanced understanding of business relationships, business requirements and worked for technical solutions to help the team at all levels until final product release.
- Experience on Edifecs tools like Specbuilder, XEngine, XEServer, and Transaction management.
- Expertise in Information Technology/ Data/ Process Management with emphasis on Business Systems Analysis.
- Gathered good knowledge of Medical and Healthcare Standards and Regulatory vehicles such as HIPAA, FDA, ICD, MMIS, EDI, and HL7.
- Efficient in conducting workshops and Joint Application Development (JAD) sessions, Project meetings, Reviews and walk through sessions.
- Earned good knowledge in RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administrator, SQL Enterprise manager, data analysis and reporting.
- Expertise using MS Visio, Rational Requisite Pro for modeling and capturing business requirements.
- Excellent knowledge on 837i, 837P, 837d, 835, 834, 276/277, 270/271, 278, 820 HIPAA transactions.
- Experience in developing project plans using MS Project and MS Share Point, identifying documents, and validating requirements and reengineering process.
- Experienced in creating test plans, test cases, test results analysis with the testing team and reporting defect management and test status matrices.
- Excellent communication and presentation skills. Experience working with business users as well as senior management.
SDLC Methodologies: Agile, RUP, Waterfall, Rapid Application Development (RAD), V-Model
Requirement Management: MS Visio 2010, MS Office, Rational Requisite Pro, Rational DOOR, MS Paint
Project Management: MS Project 2010, MS Office 2010, Lotus Notes, MS Outlook
Presentation: MS PowerPoint 2010
Database: SQL Server, Oracle, Data Studio, MS Access, DB2
Change Management Rational Clear Quest
Version Control: Rational Clear Case, MS SharePoint 2010 (MOSS 2010)
Operating System: Window XP, Window Vista, Window 7
Programming Languages: C, C++, HTML, XML
Data Modeling Analysis: Rational Rose, Power Designer 16, MS Visio, TOAD data modeler
Confidential, Baton Rouge LA
Business Analyst /EDI Analyst
- Consulted BCBSLA Stakeholders on the use of 5010 Implementation Guides and Trading Partner agreements for EDI.
- Developed several baseline assessments for EDI, Privacy, and Security. Analyzed current business processes for areas impacted by HIPAA.
- Gathered Requirements separately for EDI and Web applications.
- Analyzed the requirements and created mapping specifications based on HIPAA implementation guidelines.
- Created inbound maps to convert and load from EDI ANSI X12 format into Database tables and flat files.
- Responsible for creating validation rules for HIPAA 837/835/997 on Edifecs SpecBuilder.
- Performed GAP analysis and converted maps from one version to another as per customer/business requirements.
- Created HIPAA compliant test data for 837 Institutional and professional claims using tools like Edifecs Spec Builder.
- Involved with developing UML Designs, high-level business and technical requirements for 834, 824 HIPAA EDI Implementations.
- Identified the issues and done gap analysis with existing and current RDS Extract system for Reconciliation process.
- Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
- Tested the HIPPA EDI 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data on different modules.
- Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
Environment: OO Modeling, Web Sphere, Rational RequisitePro, EDIFECS, SQL, Rational Rose, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.
Confidential, Basking Ridge, NJ
Business Analyst/EDI Analyst
- Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
- Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
- Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
- Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
- HIPAA EDI transactions such as 834,835, 837 (P, D, I) 276, 277, 278.
- Worked with Confidential teams to get current work flow for detailed business process.
- Defined Functional Test Cases, documented, Executed test script in Facets system.
- 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.
- Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
- Coordinating and Developing QA activities.
- 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 (UAT), documented the in detail defects using the Defect Tracking report.
- Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
- 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
- Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
- Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.
Environment: Requisite Pro, Rational Rose, Agile, PL/SQL, HTML, MS Office, MS Visio, EDI, UML.
Business Analyst/ EDI Analyst
- Extensively involved in maintaining requirements traceability and communicating any changes to these requirements to different business groups and programmers.
- Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
- Gained understanding of Medicaid policy and billing requirements and documented needed changes to policies and billing manuals related to ICD10 through facilitation with internal KMHP program areas.
- Conducted Business Requirements, Functional and Technical meetings with Business groups.
- Conduct complex documentation and user needs analysis. Interface with team and staff to develop HL7 integration.
- 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.
- Involved in HIPAA EDI transactions such as 270, 271,837 (P, D, I), 276, 277, 834, 820, 278,999/TA1, and 277 CA.
- As EDI Coordinator helped the coordinators’ to create resource plan, daily MI’s, feedback forms to monitor the progress of the delegates,
- Performed Requirement Analysis by gathering both functional and non functional requirements based on interactions with the process owners & stake holders and document analysis, represented them in Requirements Traceability Matrix (RTM).
- Designed and documented test plan, test strategies, test cases in EDI Test Manager by evaluating the requirement document in Requisite Pro and performed hands-on testing for complex test conditions, scenarios and scripts so HIPPA transactions in EDI formats are verified.
- Validated all the incoming/Outgoing data from EDI 837/835 interfaces.
- Involved in Testing Various EDI transactions like 837, 835,834,276,278.
- Acted as User Acceptance Testing coordinator and monitored business testing and interfaced with the development team regarding defect status and fixes on a daily basis.
- Utilized corporation developed Agile SDLC methodology. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
- Extensive success in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) in an SOA environment.
- Exposure to Meditech software for health information management, Revenue cycle, scheduling and referral management.
- Developed and conducted statewide HIPAA 5010 and ICD-10 awareness program for all IDS staff in Tenet.
- Tested claims adjudication and group and enrollment in Amisys for New Medicare advantage members.
- Incorporated HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9 ICD-10 coding and HL7.
- Generated test data using X12 generator for transactions 837P/I/D. Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
- Appreciated for mastering a Claims management product called Curam and providing the team with guidance on the application.
- 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.
- Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
- Worked closely with the QA Team Lead in Creation, Preparation, and Implementation of quality assurance reviews and the development and execution of test plans Manually
- Involved in creation and execution of manual test cases in Mercury Test Director and automated Test Cases in QTP and analyzed the Test Results.
Confidential, Chicago IL
- Interacted with business heads to finalize the Business Requirements for the application.
- Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
- Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
- Involved with the coders in evaluation of CPT and ICD-9 codes to ensure that the diagnosis meets medical necessity for the specific CPT code.
- Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
- Involved in mentoring specific projects in application of the new SDLC based on the Agile Unified Process, especially from the project management, requirements and architecture perspectives.
- Defined Functional Test Cases, documented, Executed test script in Facets system
- Represent Operations Team as Client Liaison for Medicare Part D Plan.
- Provided clear and concise documentation regarding requirements management plans, Functional Requirements, supplemental Requirements, Test Plans and Test Cases.
- Conducted Joint Application Development (JAD) sessions with IT groups. Identified the Key Changes, and participated in Stakeholder Management to communicate effectively with them
- Implemented Data Modeling standards, including element-naming conventions.
- Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
- Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
- Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
- Followed the UML based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, State Chart Diagrams, Sequence Diagrams and Collaboration Diagrams.
Environment: Rational Rose and Requisite Pro, MS Visio, MS Office, MS Project, Agile, UML, XML, Windows XP, NT/2000, HTML, Cobol, DB2, SQL Server 2000, JAVA, J2EE, HL7, Vignette Content management Tool