SUMMARY:

• Sr. Business system Analyst Consultant with diverse experience in Business Modeling, Document Processing, EDI, Mapping HIPAA Regulatory changes and Application Integration in healthcare domain. Have extensive experience with analysis and review of software and business requirement documents and document management. Experienced in gathering business requirements, JAD Sessions, Gap Analysis, UML diagrams, Process Flows, Business Documentation, Claims
• Processing & Testing and Claims Adjudication for Medicare and Medicaid, Data Mapping/Modeling, Trizetto Facets 4.x and Medical Billing. Specialized in ANSI 4010/5010 or ICD 9/10 implementation. Worked in all types of software development methodologies including Agile, Waterfall & Scrum. Highly motivated self - starter and capable of working independently.
• Specialized in Healthcare, Risk and Compliance and Document Management.
• Experienced in GAP analysis of HIPAA with particular attention to qualifier, length and required field and situational rules and professional knowledge of HL7 standards.
• Verified and documented HIPAA regulator changes found when moving from .
• Transaction Mapping - Full transaction knowledge.
• Revitalized requirement elicitation techniques, conducted user interviews and JAD sessions and managed the requirements using Rational Requisite Pro and Use Case Modeling with all phases of SDLC.
• Conducted Impact Analysis, Risk analysis and Risk mitigation.
• Excellent knowledge of Medicaid Management information System (MMIS).
• Designed Graphical User Interface using Adobe Photoshop. Knowledge of DB2, SQL queries using MS Access and Oracle.
• Knowledge of Health exchanges: off marketplace exchange and on marketplace exchange. Federally Facilitated marketplace, state partnership Marketplace, State based marketplace.
• Experience with TriZetto FACETS and HIPAA Gateway - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Experience working with EDI transactions - 834, 835, 837 & 820 for Enrollment, Claims (Inbound & Outbound) and Premium Payments.
• Proficient understanding of Medicare Part A, Part B, Part C and Part D products and procedures managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans.
• In-depth knowledge of payer operations including claims, enrollment, eligibility, underwriting.
• Experience and excellent knowledge of Claims Adjudication Process.
• Synthesized 4010 and 5010 HIPAA implementation guide s related to Claim Testing and Medical Billing.
• Perceived ITIL Framework and the various areas of IT service delivery and support including Configuration Management, Vendor Management, and Incident Management, Customer Relationship Management, Infrastructure Management and Portfolio/Project management.
• Substantiated Object Oriented Analysis and Design representation techniques in UML using Rational Rose, Dataflow Process Modeling and Analysis & Design with Interaction and Class diagrams.
• Executed advanced level SQL queries to verify data integrity of the databases.
• Excellent knowledge and hands on experience with SSRS reporting systems.
• Experience with Trizetto’s Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, and Utilization Management.
• Scheduled meetings and reinforced business analysis with developers, system analysts and testers to collaborate rescore allocation and project completion using MS Project.
• Have worked with SAS (Statistical Analysis System) Integrated system, particularly in the modules w.r.t. Data Analysis, Performance and Risk Management.
• Experience with Trizetto’s QNXT 4.8 -good knowledge of all QNXT modules

EXPERIENCE:

Confidential

Sr. Business System Analyst

Responsibilities:

• Analyzed change requirements for Providers, Contracts and Claims processing modules configuration in QNXT system for Medicaid and Medicare Advantage for AL, FL, GA, IL (ICP &MMAI), IN, MD, MS, NC, SC, PA and TN plans.
• Supporting the Project Manager in co-ordination, scheduling and planning activities.
• Defined and documented the vision and scope of the project.
• Creating GAP analysis report and conducting Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Used a mix of SDLC Process and Agile Methodology while working on the projects in order to be able to deliver in a phased approach and meet the deadlines.
• Worked with the data architecture and data analyst team in designing the model and in creation of the data mapping documents
• Gathered requirements, developed Process Model and detailed Business Policies.
• Worked with SSIS for data transformation and defining To-Be processes.
• Developed several detail and summary reports including line and pie charts, trend analysis reports and sub-reports according to business requirements using SQL Server Reporting Services (SSRS).
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Participated in various meetings and discussed Enhancement and Modification Request issues.
• Attended and facilitated weekly meeting to discuss progress and modification to plans due to change in business requirements.
• Created/authored documents like High Level Requirements and Detailed Level Requirements document
• Designed Graphical User Interface using Adobe Photoshop. Knowledge of DB2, SQL queries using MS Access and Oracle.
• Used SQL Server Reporting Services to migrate and convert crystal Reports into SSRS.
• Created documents to address simple work efforts that required less than 80 hours of design and testing before implementation to address new business requests.
• Also verified the test scripts before manual execution if they cover all the aspects of rate and quote details according to State Medicaid and Medicare Policy coverage selection
• Supported Medicare & Retirement goals of affordability, excellence, engagement and growth.
• Configured Providers (Individual, Group and IPAs) per Provider Change Management application (PCMA) load information and utilize Contracts module to identify appropriate contracts and networks for non/credentialed providers using legacy fee tables crosswalks, signed contracts, NPI Registry, EDI 835 & 837 Claim image (1500 & UB04).
• Analyzed HIPAA 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
• Worked on Electronic health record system as a CRM web based application.
• Gathered managed care specific business requirements from several different managed care programs.
• Utilized Member module to verify eligibility, benefits and PCP assignment to maintain accuracy.
• Updated and analyze Claims 101 edit errors for missing contracts in an accurate and timely manner to avoid penalties.
• Ensured system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
• Created BRD and FRD for Medicaid managed care requirements and documenting them.
• Acted as a SME for the application team and the Infrastructure team.
• Provided SDLC Methodology for developing EDI applications used by hospitals to completely automate payments posting for Medicare, Medicaid and commercial payers electronic payments files.
• Executed advanced level SQL queries to verify data integrity of the databases.
• Work closely with IT staff to automate testing processes whenever possible to reduce configuration errors.
• Correct and maintain audit errors log to ensure high accuracy and productivity.
• Provide analysis and conduct testing for change requests, software releases, and fixes.
• Ensure departmental documentation, daily and weekly reporting is being completed timely and accurately.

Environment: Trizetto QNXT (Provider, Contract, Member, Claims Modules), MS-Visio, Excel, Access, MS-Word, MS-Power Point, SSRS, SSIS, SQL

Confidential, Ewing, NJ

Sr. Business Systems Analyst

Responsibilities:

• Conducted JAD sessions with Subject Matter Experts (SME’s)
• Played an active role in gathering, analyzing, and writing business requirements
• Followed the RUP and UML methodology throughout the SDLC
• Developed Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/ Medicaid claims processing.
• Performed Gap analysis for better understanding of transition from HIPAA 4010 to HIPAA 5010
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML
• Documented, organized and tracked the requirements using Rational Requisite Pro
• Worked on ICD conversion from 9 to 10 with respect to the claims related to Medicare (Part A, Part B, Part C, and Part D)
• Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis & compliance experience from, payers, providers and exchanges perspective, with primary focus on Coordination of benefits
• Acted as a Business Analyst for the CDS implementation the backbone for data integration among myriad systems, including ERP, CRM, Portal, Workflow Engine, Payroll and related interface
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying
• Created Use Cases using UML and managed the entire functional requirements life cycle using Rational Unified Process, Requisite Pro
• Communicated new BPMN with client and suggested best solution to make the changes according to new regulation
• Derived BPMN for batch loading of Provider and Member data into FACETS
• Ensured system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
• Performed gap analysis by matching the requirements for managed care programs.
• Proposed innovative solutions for the project to increase efficiency
• Generated reports for various projects using HP Quality Center and Rational Clear Quest
• Created and maintained the Requirements Traceability Matrix (RTM)
• Created EDI Export and Import processes and worked with EDI Trading Partners, Payers/Vendors.
• Generated the sequence, state chart, and activity diagrams to enable understanding and representation of the business processes for ease of software system development in Rational Unified Process (RUP) methodologies using Rational Rose

Environment: MS-Visio, Excel, Access, MS-Word, MS-Power Point, SSRS, SSIS, SQL, ClearQuest, BluWorks

Confidential, Long Beach, CA

Sr. Business System Analyst

Responsibilities:

• Created Business Analysis risk analysis to make sure project is on track and what factors can affect the timeline of the project.
• Manage and share all formal and information project deliverables in SharePoint under project specific site.
• Created new templates for the Business Analysis team to use on various projects.
• Applied and shared best practices with the Business Analysis team for them to apply it on several projects within the firm.
• Conducted JAD sessions with Subject Matter Experts (SME's).
• Strong knowledge of managed care payer requirements and procedures.
• Did Presentations making Stakeholders understand how the changes would affect different modules w.r.t. Medicare and Medicaid.
• Conducted business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Conducted User Acceptance Testing (UAT) prior to and after implementation phase.
• Created daily, monthly reports and online guides for all Care Center users; Participated in Care Center projects with other units to design, test and implement new applications; Managed Care Center databases.
• Worked on conversion from ICD-9 to ICD-10 with respect to the claims related to Medicare (Part A, Part B, Part C, Part D).
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
• Assist end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS (Data Base Management System).
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Part of the team for migration of HIPAA - EDI ANSI (ASC) - X12 4010 series to ANSI (ASC) - X125010 series for EDI Transaction code sets: 820, 834, 835, and 837 (I, P and D).
• Performed GAP analysis of 4010 and 5010 EDI transactions 270, 271, 276, 277 and 999 using implementation guide to identify the changes in the segments and data elements.
• Completed a review of existing documentation for orders, referrals and reports and compared it to the clinical details needed for ICD-10.
• Involved with ICD-10 implementation testing.
• Assisted in writing test case scenarios and performed Claims Unit testing, Regression testing, Integration testing and Compliance testing.
• Extensively worked on Facets, the claim processing tool used in the project.
• Involved in configuration of Facets Provider and Subscriber/Member Application group.
• Analyzed the member/eligibility information on claim to that in Facets.
• Worked on Facets to efficiently execute core administrative functions, including claims processing, premium billing and customer service.
• Worked with SME close to analyze the Claim Adjudication Process setup in Facets.
• Implemented automated COB (Coordination of Benefits) processing of Medicare claims into Facets.
• Worked with Claims, enrollment, eligibility, benefits verification for members and providers, benefits setup, and backend payment cycle in Facets.
• Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.
• Done Business Process Modeling for representing processes of an enterprise, so that the current process may be analyzed or improved.
• Created Business Process Modeling workflows for projects using Microsoft Visio.
• Worked on ETL (Extract, transform, load) -based design.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Responsible for development/implementation of systems project or cross functional teams focused on the delivery of the Electronic Health Record or any systems associated with the EHR.
• Conducted training sessions on EHR application and suites.
• Working with respect to EHR towards standardization in methodology, performing testing and implementation and build, error proofing, and data integrity and LEAN methods.
• Facilitating Sprint planning, Daily Scrum, Sprint Review, Dev validation/ Story estimation, defect prioritization, retrospective as Scrum master for 5 Scrum teams under Agile - Scrum methodology.
• Work with stake holders / product owners under Agile - Scrum methodology to prioritize the User Stories for Sprint.
• Allowed the User Stories under Agile - Scrum methodology into the Sprint based on team velocity and individual capacity.
• Coached and mentored5 Agile teams containing a total of 54 team members.
• Motivated the team under Agile - Scrum methodology to come up with quality shippable product and meet the product goals.
• Worked with Product owners under Agile - Scrum methodology on artifacts Such as Product Backlog, Spring Backlog, Sprint burn up / Burn-down, and Release Burn up / Burn-down.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Performed manual testing, including validation/smoke testing of HL7 interface messages on each new build before delivering to the quality assurance team.

Environment: MS-Project, Visio, Rational Rose, Requisite Pro, Clear Quest, QC, QTP,ANSI (ASC) - X12 - EDI, Oracle, Facets, Agile, TFS 2012.

Confidential, San Diego, CA

Business System Analyst

Responsibilities -

• Acted as a primary contact in all the phases of Software Development Life Cycle SDLC, including Quality Assurance Testing, Performance & User Acceptance testing.
• Performed GAP analysis for ICD-9 and ICD-10 and EDI Message Structure with the 4010 Structure. Developed End-to-End Business Process Flows for HIPAA 5010 EDI transactions including 834 (Benefit Enrollment and Maintenance), 835 (ERN-Electronic Remittance Notification) and 837 (Claims Submission) Transactions.
• Worked in the analysis of the ICD 9 - ICD 10 codes conversion Project using GEM (general Equivalence mapping) processes and concepts. Worked in a project involving Miami Systems to create Drug Cards and created Test files to be sent to drug card vendors for approval.
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management.
• Worked on a Paid without prejudice project for various States. Performed UAT tests using the (MORAE) Usability Testing Tool using the Observer and the Manager Mode.
• Responsible for integrating with Facets EDI 834 transactions. Analyzed EDI 834 and ensured the format and the contents are in correct form. Information such as the subscribers name and identification, plan network identification, subscriber’s eligibility and services were analyzed.
• Analyzed the existing 820 reports and modified them based on the changes resulting from the Health Insurance Exchange (HIX)
• Worked on analysis of FACETS claims processing system and to gathered requirements to comply with HIPAA 5010 requirements
• Maintained knowledge of Medicare and Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations
• Involved in claims and record data mapping and data modeling with technical teams.
• Designing test scripts for testing of Claims in Development, Integration and production environment.
• Created source table definitions in the Data Stage Repository by studying the data sources.
• Generated Surrogate ID’s for the dimensions in the fact table for indexed and faster access of data.
• The process included importing claims into Facets that had been adjudicated and setting them in a “PAY” status so that a payment cycle could be run to create checks on Facets.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Experience in writing SQL queries, Stored Procedures and Triggers.
• Worked extensively with Tableau and MS Excel for the generating of reports.
• Worked with FACETS, eBilling and EDI HIPAA Claims(837/835/834) processing.
• Worked on Claim Statue Inquiry (276) and Claim Statue Response (277) HIPAA EDI transactions and Code Sets and validation to ensure the integration with Facets mandates the Federal regulation.
• Responsible for architecting integrated HIPAA, Medicare solutions, and Facets EDI 834.
• Used SSRS for generating reports regarding the data and to verify the integrity of the data.
• Worked with SSIS for data transformation and defining To-Be processes.
• Developed test Scripts using Test Director/Quality Center and coordinated with developers to quickly resolve the defects associated with them.
• Involved in the testing of web portal of new MMIS system.
• Conducted JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications. Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions to test the performance of the application from various dimensions.
• Helped create the 'Business Glossary' to facilitate efficient understanding of the business process amongst the other teams. Assisted in creation of the Functional Design Document from the Business Requirements Document which was used as the reference by the development team while preparing the design and held the responsibility of the required data setup for unit testing.
• Worked extensively in the executing of SQL queries on the database to verify data integrity.

Environment: IDX, MS Visio, Word, Excel, PowerPoint, CMMI,MMIS, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, Oracle, SSRS, SSIS, J2EE technology.

Confidential, Raleigh, NC

Business System Analyst

Responsibilities:

• Developed Test Plans and Test Cases to test the GUI and workflow for Quality Assurance.
• Maintaining knowledge of Medicare and Medicaid rules and regulations and evaluating the impact of proposed changes in rules and regulations.
• Validate EDI Claim Process according to HIPAA compliance.
• Worked with Denver Department of Human Services and performed comprehensive business analysis of Eligibility and Enrollment Processes for Potential Medicaid Members and Newborns for a Quality Improvement Process initiative and State Children’s Health Insurance Plan (SCHIP) programs.
• Excellent understanding of Software Development Life Cycle (SDLC) models.
• Responsible for architecting integrated HIPAA, Medicare solutions, and Facets EDI 834.
• Participated in changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Used Quality Center to plan tests, manages test assets, create and run manual and external scripts to check GUI and functional features of the AUT
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Performed Data Validation using SQL Queries.
• Designed SSIS Packages to extract, transfer, load (ETL) existing data into SQL Server from different environments for the SSAS cubes.
• Expertise in problem solving and bug tracking using Quality Center.
• Querying and testing using Oracle.
• Performed UAT by formally documenting the results of each test and provided error reports and correction requests to the developers
• Responsible for designing and performing User Acceptance Test evaluations that ensure adherence to the company’s quality assurance standards. Assured compliance with company and/or external requirements and specifications for user acceptance testing.
• Performed day to day Back-end testing procedures using SQL statements for various online customer interactions.
• Worked for Entrance and Exit criteria.

Environment: QTP, QC, Java/J2EE, Oracle, Windows, HIPAA, MS Excel, MS Office

Confidential, Oklahoma City, OK

Business Analyst

Responsibilities:

• Extensively worked with SME to better understand the existing claim processing at Confidential .
• Performed and analyzed GAP Analysis of EDI 837 transaction from .
• Worked in testing the Professional, Institutional Claims processing and adjudication and validate data with FACETS.
• Organized and facilitated meetings with the management and the development team to better understand Business Requirement.
• Conducted a session with business, SME and other parties to gather the requirement for the integration of Facets with the providers and other third parties.
• Gather requirements after JAD sessions with the purpose of defining the functional business and system requirements.
• Identified the scope, business objective and documented the functional requirements for each release.
• Determined how the changes in HIPAA-5010 impact current business operations to define and develop business and technical requirements within and across transactions.
• Worked extensively in FACETS to define the As-Is and To-Be Claims Adjudication process.
• Worked on analysis of FACETS claims processing system and to gathered requirements to comply with HIPAA 5010 requirements
• Directly involved in process improvement Plans and implementing business change, creating and managing Project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Used MS-Visio to create Data Flow Diagrams as a Structured Analysis tool.
• Developed Business flow diagrams, Activity/State diagrams and Sequence diagrams so that the development team and other stake holders can understand the business process.
• Created artifacts for Rational Unified Process (RUP) - system architecture document, supplemental requirements document, architecture diagrams; verifying technical production infrastructure; designing and executing performance tests; and documentation.
• Wrote clear, concise and detailed system requirements specification (SRS) documents and user documentation in accordance to guidelines and standards of a level where developers can interpret and design and develop the application with minimum guidance.
• Developed Business flow diagrams, Activity/State diagrams and Sequence diagrams so that the development team and other stake holders can understand the business process.
• Worked closely with QA team and Developer to establish traceability matrix to ensure the completeness of the enrollment procedure.
• Guided QA team to write test cases and test scripts to confirm the displayed information and also tested to print the image in the paper.
• Performed functional testing of the application as per the 5010 changes.
• Documented and analyzed all defects using Quality Center and tracked them to completion by communicating with the team every day.
• Supported development and Installation team.
• Performed Unit and Integration Testing.
• Implemented Alpha Test in order to confirm the functionality of recent conversion.