SUMMARY:

• 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
• 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.
• Strong experience and understanding of health care industry, enrolment, eligibility, and claims management process, Knowledge of Medicaid and Medicare Services.
• 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.
• In-Depth knowledge and extensive experience in Healthcare System: Medicare and Medicaid system.
• Strong knowledge/experience in conducting GAP Analysis and User Acceptance Testing (UAT).
• Proficient in working with healthcare payer and claims processing systems like FLEXX, EAB/CARE, PORTICO, NASCO and FACETS.

PROFFESSIONAL EXPERIENCE:

Confidential, Louisville, KY

Sr. Business Analyst /EDI Analyst

Responsibilities:

• 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
• 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).
• 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.
• Involved in gathering requirements, configuration, and data conversion of the Facets application modules like Enrollment, Membership and Claim.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Creating and validating data using SAS functions and procedures.
• Systems Documentation included Business Requirements Document (BRD), 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 (AREV) to Facets.
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Worked on Facets Claims Software System, to convert data from their legacy system (LRSP) and add custom applications to satisfy in-house requirements
• 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.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 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) .
• Validated Medical, Hospital and Dental claims in FACETS, verified Codes with description and requirements, verified adjudication process of Claims in FACETS.
• 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.
• Tested the claims processing and Adjudication (EDI 837I, 837P, 837D& EDI 835).
• Used to execute test cases for several transactions such as 837, 835, 820, 834, 277, 278, 270/271
• FACETS version upgrade implementation project and worked extensively on 837i (Institutional Claim), 837p (Professional Claims), 837D (Dental) and 834 (Enrollments).
• 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.
• 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 Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• 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. Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicare Part C and Part D Claims.
• 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, and data dictionary and data analysis.
• Identified Actors, Activities, Artifacts and Workflows and developed use case diagrams using Rational Rose.
• 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 Analyst / EDI Analyst

Responsibilities:

• 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.
• Identified file changes and data relationships associated with Facets application upgrade and defined impact on customer implementation.
• 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 999.
• Reviewed various customer transactions using the FACETS application.
• 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 837, 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.
• Regression Testing of Web applications and applications dealing with MEDICAID and MEDICARE Services
• 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.
• Participating in all facets of the standard project life cycle and ensured smooth transition of projects to production support.
• Got involved in designing future state processes for HIPAA 5010 transaction processing EDI 820, 834, 835and 999.
• 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
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/ Medicaid claims processing.
• Generated XML documents using the XML Output Stage.
• Worked in FACETS Reconfiguration of member/subscriber, Data Element Definition and Usage with values and completed configuring FACETS Applications like Related Entity, Parent Group, Group, and Subgroup using Data Toolset.
• Reviewed various customer transactions using the FACETS application.
• 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

Responsibilities:

• 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 (4010)/ 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.
• 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).
• 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 (CCR).

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

Confidential, Boston, MA

Business Analyst EDI Analyst

Responsibilities:

• 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.
• Involved in HIPAA/EDI Medical Claims, Design and Documentation
• Performed testing for Medicare, Medicaid for Medicaid Management Information System (MMIS)
• 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
• Conducted Claims and HIPAA Compliance Training to run the test cases. Also worked with NPI
• 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.
• Prepared BRD 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.
• Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Identifying and understanding the business critical areas from the user perspective.

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