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Sr. Business System Analyst /edi Analyst Resume

Louisville, KY


  • Extensive experience of 7+ years, in design, development and implementation of business applications.
  • Extensive experience in the development, implementation, deployment and integration strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills
  • Possesses experience in Implementation of Systems/Applications and Database design in a variety of environments with expertise in Client/Server Architecture.
  • Extensive experience in section 508 compliance.
  • Exceptional ability to build Client relationships through frequent meetings, one on one interaction, and/with ability to converse with all facets in the client organization by utilizing elicitation techniques like interviewing, questionnaires, brainstorming, focus groups, prototyping, cost/benefit and risk analysis.
  • Extensive experience working with welfare programs.
  • 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.
  • Full understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Test Manager, Unified Modeling Language (UML).
  • Worked on eligibility for help with child care cost, food stamp and Medicaid health insurance.
  • Firm understanding of the Software Development Life Cycle (SDLC).
  • Extensive study of interaction patterns between business processes to ensure proper collaboration.
  • Externalized business processes in different projects as web services moving towards a service oriented architecture.
  • Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicare, and implementation of HIPAA key EDI (ANSI X12) transactions.
  • Experienced in gathering requirements for HIPPA (Health Insurance Portability and Accountability Act) EDI (Electronic Data Interchange) Transactions 820, 834, 835, 837 (I, P and D), 270, 271, 276, 277, 278, 997 and 999 in various phases of implementation.
  • Involved in HIPAA gateway transactions 997/999 and converting HIPAA 4010 messages into HIPAA 5010.
  • Well-versed experience in all EDI transactions like 834, 837, 835 and conversion of .
  • Dealt with the complexity of migrating from the ICD-9 set of diagnostic codes to ICD-10.
  • Assisted Project Teams in preparing technical design documents Software Requirement Specifications (SRS), User Interface Design, designing of Application Architecture & Database Modeling as per as RUP (Iterative) process.
  • Experienced in conducting Rapid Application Development (RAD) and Joint Application Development (JAD) sessions to converge early towards a design acceptable to the client and feasible for the developers and to limit a projects exposure to the forces of change.
  • Strong knowledge/experience in conducting GAP Analysis and User Acceptance Testing (UAT).


Methodologies: RUP, Agile, CMMI, CMM, Six Sigma, OOAD, UML, Business Modeling, Process Modeling and Data Modeling

Office Tools: MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, Lotus Notes

Process/Modeling tools: MS Visio, Rational Rose, Rational Requisite Pro, Smart Draw, Clear Case, Clear Quest

Testing Tools: Test Director, Quality Center, Win Runner. Selenium

Operating Systems: Windows Vista, NT/2000/2003/ XP/98, MS DOS, UNIX/LINUX

Quality Management: HIPAA, CMMI, CMM, MAPIR, Six Sigma, TQM

Languages: C/C++, Java, SQL, PL/SQL, HTML, XML, ebXML, Peoplesoft v 9.1

Database: MS Access, SQL Server 2000, Oracle 9i & 10g, Teradata.

Other Tools: Macromedia Dream Weaver, Macromedia Flash and Adobe Photoshop, Salesforce, WebLogic Server 11


Confidential, Louisville, KY

Sr. Business System Analyst /EDI Analyst


  • Ensured all artifacts complied with HIPAA 5010 policies and guidelines.
  • Formulated and defined systems scope and objectives through research, data mining, analytics and fact-finding.
  • GAP Analysis: Analyzed the client’s applications programs to determine the impact of the HIPAA final rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance
  • Created ETL documentation such as EDI X12 837(P,I), 834 and 835 Data Mapping, Transformation logic for Main Frame Layout, Updating Meta data documents for new Platform.
  • Creating and validating data using SAS functions and procedures.
  • Systems Documentation included Business Requirements Document, Systems Requirement Specification (SRS) and test plans using Requisite Pro.
  • SME for Oracle Letter generation based on the HIPAA guidelines involved in protecting the patients information
  • Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.
  • Worked on project migration of all Healthcare Process (such as EAB, Products, Provider, Claims, Capitation, Voucher, finance etc) for Dental HMO from Legacy system to Facets.
  • Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 835, 837 (I,P,D) and 820) standards
  • Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
  • Re-engineered and captured EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
  • Working experience for Dental, Professional and Institutional Claims (UBO4 and 837D, 837P & 837I).
  • Integrated Requisite Pro with Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
  • Supported technical team members for technologies such as SSAS, Microsoft Excel and SQL server.
  • Involved in writing complex SQL queries to check the data integrity.
  • Analyzing User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
  • Involved in the complete business process redesign and reengineering effort in converting existing process into a strategic web based environment.
  • Used SOAP UI, Web Logic Server 11 ANT task to test Web Services running on Web Logic Server11
  • Performed extensive data modeling to differentiate between the OLTP and Data Warehouse data models.
  • Worked on Facets Claims Processing for data validation and claims validation. Extensively worked on Claims Inquiry and Dental Claims Processing.
  • Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
  • Analyzed EDI transactions in XML and X12 responses.
  • Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.
  • Identified Actors, Activities, Artifacts and Workflows and developed use case diagrams using Rational Rose.
  • Developed reports using SQL in MS SQL Server environment
  • Run automated ruby scripts on a UNIX/LINUX machine.
  • Re-Organized the collected data and prepared documentation for implementation.
  • Created Activity Diagrams, Sequence Diagrams and ER Diagrams
  • Worked with relational databases, and developed PL/SQL queries to interact with Databases.
  • Experience in relational databases (RDBMS) like Oracle, SQL, and MS Access.

Environment: HIPAA, SAS, MS Excel, EDI 837I and 837P, Pharmacy, Web Logic Server, SQL, Share point, Toad, Word, Excel, Magic/app, UNIX/LINUX

Confidential, Dayton, OH

Business System Analyst / EDI Analyst


  • Involved in gathering and creating functional and non-functional requirement documents, IRD’s, Use Cases, Wire Frames, end to end system work flows, interface diagrams, mapping documents, presentations, message specifications, test scripts for enrolling and maintaining groups and individuals.
  • Created architecture Solution flows, UML diagrams, service charters and detailed message specifications for development of messages/interfaces which using Business Process Modeling Notations (BPMN).
  • Created Requirements Traceability Matrix and support in creation of enterprise solution architecture to integrate business rules across domains.
  • Part of the team for migration of HIPAA - EDI ANSI (ASC) - X12 4010 series to ANSI (ASC) - X12 5010 series for EDI Transaction code sets: 820, 834, 835 and 999.
  • Responsible for creating and maintaining documentation related to the project including scope document, vision document, functional specification document, defect status report, mitigation plans, supplementary requirements specification document and impact analysis document.
  • Extensively worked on preparing the test plan and test cases for EDI transaction like, 834, 835, 270/271, 276/277, 278.
  • Responsible for configuring the following under the Dental Plan application: Benefit Summary, Class/Plan Definition, Component Prefix Def, Deductible Rules, Dental Category Payment, Dental Category, Rule Def, Duplicate Claims Rules, Dental Procedure/Category Conv., Duplicate Claim Rules, Dental, Network Set, Limit Rules, Plan Description, Premium Rate Table, Product, Processing Control Agent, R&C Schedule, Dental, User Warning Message, Warning Message.
  • Through business process reengineering, designed the most cost effective and competitive business processes possible.
  • Worked on different EDI transactions like 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270/271 for Eligibility inquiry, and 276/277 for claims status.
  • Worked on the EDI 834 inbound and 834 outbound data movement with our trading partners.
  • Conducted process mapping to identify current As-Is business processes and To-Be road map for reengineering the products.
  • Validated 835, 837, 276, 277, Institutional and Professional HIPAA Transaction and X12 format messages.
  • Performed Database testing using DB2 Connect and Extra tools for verification of data tables in database.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 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 activities to make sure proper documentation and standards are being followed.
  • Created mapping documents for 837 Institutional, Professional and Dental claims
  • Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
  • Extensively worked on Data Migration from Informatica to SQL- SSIS
  • Strong visual modeling and business process modeling skills in Rational Unified Process (RUP) and Agile Modeling with tools like Rational Rose, MS Visio.
  • Got involved in designing future state processes for HIPAA 5010 transaction processing EDI 820, 834, 835and 999.
  • Maintained daily SQL (SSIS, SSRS) reporting, ad-hoc reporting
  • Extensively created Business Process Modeling Diagrams/Swim Lane Flows using BPMN notations and MS Visio indicating transformations and feeds.
  • Created crosswalks to support list of values across enterprise for reusability and for supporting CDM.
  • Performed extensive GAP analysis and created Message Specification Documents for service calls.
  • Reviewed WSDLs created through IRD’s and Message Specifications used for enrolling & maintaining groups and members.
  • Developed Customer Service Inquiry chart for Dental and Vision providers. Wrote Use Cases, prepared use case diagrams (using Rational Rose) and followed Rational Unified Process at every stage of the process.
  • Performed Data Profiling and Data Quality.
  • Used ERwin for data modeling.
  • Extensively involved in Data Extraction, Transformation and Loading (ETL process) from Source to target systems using Informatica Power Center.
  • Worked closely with lead Data Warehouse developers to evaluate impact on current implementation, redesign of all ETL logic
  • Debugged SQL queries as a reengineering process to any problems or errors found.
  • Responsible for Data Extraction, Data Compilation, Data Analysis, Data Manipulation and Data Validation using SQL queries in a MS SQL Server 2005 environment
  • Generated XML documents using the XML Output Stage.
  • Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
  • Gather interface requirements across platforms to support business rules and HCR changes (EDI 834)
  • Create metadata and provide assistance for development of Canonical Data Model for members, groups, billing & payments.
  • Extensively involved in testing data using queries and verifying test conditions created by BSA’s

Environment: Windows, MS Office (Excel), MS Visio 2.0, SharePoint, WebLogic Server HIPAA, BPMN, SSIS, UNIX/LINUX

Confidential, Virginia Beach, VA

Business System Analyst


  • Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations,
  • Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
  • Involved in documenting the business process by identifying the requirements and also involved in finding the system requirements.
  • Validated the EDI 837-claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
  • Performed Back-end Testing using PL/SQL for Database Validation.
  • Was involved in process flow analysis for content management system.
  • Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA (5010)/ EDI formats and accredited standards like ANSI.
  • Involved in creating mappings for the conversion of EDI ANSI (ASC) - X12 transactions 820, 834, 835 and 837 (I, P and D)code sets version .
  • Involved in the complete business process redesign and reengineering effort in converting existing process into a strategic web based environment.
  • Defined the scope and implemented business rules of the project, gathering business requirements and documentation.
  • Reviewed and gathered requirements from the Subject Matter Experts (SME) and Business Partners using various elicitation techniques and create Scope Management Documents,
  • Worked in creating interfaces for various external vendors
  • Created Technical Specifications for the 835 and 837 I and P files with their changed and new contents to create 5010 complaint files.
  • Worked with relational databases, and developed PL/SQL queries to interact with Databases.
  • Created Pre-determination for the dental claims.
  • Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions include 837, 835, 276, 277 (both inbound and outbound) transactions
  • Facilitated JAD sessions and elicited customer requirements by organizing interviews with internal/external stakeholders and subject matter experts (SMEs) to create subject specific questionnaires for clinical trials.
  • Reviewed administrative and clinical practices and procedures: point of care, scheduling, registration, clinical documentation, patient care, and charge entry, medical coding and diagnostic testing procedures associated with multiple business units.
  • Created Data Mapping to document to migrate data from the existing system to the new system.
  • Strong Documentation and Report Generation skill and experience by Use case approach.
  • Worked on adjudication and on eligibility- Enrollment, Billing, Group/Member Insurances
  • Coordinated with the different teams distributed at different geographic locations for various releases.
  • Data mapping on Enrollment Module (EDI 834) of FACETS.
  • Part of the team for migration of HIPAA - EDI X12 4010 series to 5010 series for EDI Transaction code sets: 820, 834, 835, and 837 (I, P and D).
  • Created workflow diagrams, process flow and data flow diagrams
  • Assisted team with Data Mapping and Data Extracting Strategies for data migration.
  • Involved in creating use case diagrams for the purpose of the team to understand the workflow of the system.
  • Analyzing the business needs for the reports and documenting the requirements in SSRS forms.
  • Facilitated JAD sessions and captured meeting minutes
  • Analyzed EDI ANSI X12 file mapping and reported in analysis spreadsheet. Performed validation of 837 (P, I) & 835 format files
  • Effectively communicated user acceptance test results between users and development team and provided recommendations for change control requests.

Environment: Facets, MS Visio, Word Excel, PowerPoint, Medicare/Medicaid, Rational Rose, Requisite Pro, SQL.

Confidential, Boston, MA

Business Analyst/EDI Analyst


  • Responsible for gaining a good understanding of User needs and accurately representing them in a well-documented software functional specifications document.
  • Gathered Business Requirements, Interacted with the Users, Designers and Developers, Project Manager and QA Team to get a better understanding of the Business Processes.
  • Interacted with the “End-Users” by interviewing them, by preparing appropriate questionnaire to better understand end-user needs and the business process.
  • Followed a structured approach to organize requirements into logical groupings such as requirements for Customer, Client, Group, Member and Reporting that critical requirements are not missed.
  • Involved in creating Business Process Documentation. Identified Use Cases from the requirements. Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams using MS-Visio.
  • For Project management purpose worked on Microsoft Project, used Microsoft Share Point for maintaining the updated Documentation.
  • Microsoft Office (Outlook, Word, Excel, Visio, Access) at various phases of development for documenting the requirements.
  • Analyzed and optimized the process, Prepared Business Requirement Document and managed requirements using Rational Requisite pro.
  • Facilitated JAD sessions with business and technical units to fine tune prioritize and detail requirements and use cases.
  • Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
  • Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter, to meet and exceed HIPAA requirements set forth by the federal government.
  • Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML.
  • Managed RTM (Requirement Traceability Matrix) to track the project flow.
  • Prepared Confidential and Derived Functional Requirement Specifications (FRS) based on User Requirement specifications and delivered to the project team. Understand and articulate business requirements from user interviews and then convert requirements in to technical specifications
  • Worked with FACETS, eBilling and EDI HIPAA Claims (837/835/834) processing.
  • Identifying and understanding the business critical areas from the user perspective.
  • Managed change of the requirements and associated requirements to other requirements for traceability using Enterprise Architect.
  • Involved in drawing data flow diagrams and process flow diagrams using MS Visio for the Claim Adjudication module.
  • Involved in generating Test Plans and Test Specifications as per Business requirements
  • Involved in conducting 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.
  • Participated in the bug review meetings, updated requirement document as per business user feedback and changes in the functionality of the application.
  • Organized meetings to discuss outstanding issues with QA team and developers.
  • Involved in User Acceptance Testing.
  • Coordinated with the development team in documenting End User Manual.

Environment: MS Office, MS Visio, UML, Rational Clear Quest, Adobe Acrobat, PL-SQL, Oracle, SDLC, SharePoint

Confidential, Glen Allen, VA

Jr. Business Analyst


  • Assisted the project manager in the creation of the project charter & vision document during the inception phase of the project.
  • Performed GAP analysis as it pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process.
  • Produced Activity diagrams with defined swim lanes as part of the claims process analysis.
  • Involved in gathering and prioritizing requirements using 1 to 1 interviews, brainstorming & developing questionnaires.
  • Translated business requirements into functional specifications and documented the work processes and information flows of the organization.
  • Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) standards.
  • Profound understanding of insurance policies like HMO, PPO, EPO and POS with proven experience in HIPPA 4010 EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim status), 834(Benefit enrollment), 835(Payment/remittance advice), 837(Health care claim).
  • Assisted in upgrading HMO Medicare EDI and reporting.
  • Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments.
  • Created a detailed use case scenario.
  • Assisted the Quality Analyst (QA) in creating test plans, test data and conducted manual testing to validate functionality.
  • Clarified to claims personnel the new Affinity payments and Explanation for payments (EOPs) for same claim processing cycle.
  • Assisted the QA in performing simple SQL queries for QA testing and data validation.

Environment: Oracle, MS Project, MS Office suite, MS SQL, Rational Suite, Citrix, MS SharePoint.

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