PROFESSIONAL SUMMARY:

• 4 years of experience with increasing responsibility in Healthcare and Information Technology in complex, computerized mainframe and client server environments.
• Assisted in ERP system implementation, and maintain system enhancements and maintenance.
• Developed client requirements and their detail design documents to implement commercial claims processing on a Medicaid platform.
• Mapped the X12: all 4010 & 5010 Transactions including NCPDP and 277U
• Good working knowledge of Claims processing, Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction Set EDI X12 837, 270/271, 276/277, 278, 834, 835
• Experienced with Claims Policies and Procedures & process flows
• Gathered requirements and implemented Managed Care Medicare programs
• Held JAD sessions for internal Claims processing department
• Performed on - site Health Plan reviews for Medicaid encounter compliance
• Implemented and maintained all EDI payer files for private, Medicaid and Medicare insurance plans
• Designed and implemented a Pharmacy Medical Administration Record (MAR)
• Gathered requirements and use case scenarios for all HIPAA X12 transactions to be upgraded to a new platform for compliance, validation and routing that included process flows
• Implemented Hospital & Home Health Pharmacy Systems Claims Fraud & Abuse
• Extensive Claim experience for Provider, Payer, Clearinghouses, Pharmacy Expert level knowledge of healthcare industry applications and processing, EDI transaction sets and formats.
• Experienced as a team leader, project coordinator, business / data analyst and client services support specialist.
• Skilled in project management, SDLC tools and methodologies, requirements definition, documentation of functional and technical specifications.
• Proven ability to develop positive relationships though team-building and mentoring junior staff.
• Strong Experience in Smoke, Functional, Regression, Performance and User Acceptance testing for the highly structural and complex systems. Extensive experience in Black Box Testing, Functionality Testing, System Testing, Regression Testing, UI Testing, User Acceptance Testing (UAT), Bug tracking system & process and Database Testing using SQL.
• Expertise in Population Health Management and Risk Adjustment experience

TECHNICAL SKILLS:

• MS Project, MS Visio, MS Excel, MS Word, MS PowerPoint, Rational Rose
• Rational Unified Process (RUP), Agile, Scrum, Waterfall, Iterative
• ARIS, and MS Visio
• HPQC
• MS Visio
• Excel advanced skills including pivot table and concatenation, Word, Power Point, and Frontpage

PROFESSIONAL EXPERIENCE:

Healthcare Business Analyst

Confidential, Bethalto, IL

Responsibilities:

• Experience in X12 EDI Transactions (834 enrollment, 820 payments, 270/271 eligibility/response, 837I and 837P institutional and professional claims, 835 Healthcare Claim Payment Advice, 277CA Claim Acknowledgement, 999 transactions)
• Experience with EDI HIPAA conversion
• Deep knowledge of healthcare business processes and EDI infrastructures
• Experience working with EDI standards (e.g., ASC X12, NSF, HL7).
• Involved several working sessions and much 'offline' research/documentation with the key stakeholders and SME's from the Pharmacy department.
• Involved in generation and execution of SQL queries to understand the processes used by the pharmacy department.
• Experienced in building and maintaining web applications using Adobes AEM CMS to include site architecture, custom components, workflow development, Digital Asset Management (DAM)
• Developed HL7 messaging for bi-directional case and disease report exchange, in HTML and XML formats, in accordance with HL7 specifications.
• Lead all aspects of HEDIS, up to and including budget, Roadmap preparations/collections; onsite/telephonic visit arrangements between auditors and internal departments/external vendors; managing timelines and resources; completions and submissions of approved HEDIS related documents to auditors; IDSS/NCQA data submission process.
• Performed Gap Analysis by identifying current technology, policies, and procedures, documenting the enhancements for the requirements, and analyzing new HIPAA 5010 compliance and developed an action plan for the migration process.
• Worked as a liaison between the business client and development team for the implementation 5010 transition in compliance with HIPAA standards.
• Involved in analyzing and understanding Business Epics.
• Clarifying requirements which are not clear with Business Analyst.
• Collecting test data for requirements to perform testing.
• Analyze requirements to ensure testability, report gaps and discrepancies.
• Creating and executing test cases for GUI, Sanity, Smoke, Functional and Regression testing.
• Performed Peer review for testing related documents Test cases, Test Plan and Release summary document
• Executing test cases and log defects in JIRA.
• Retest the scenarios post defect fix.
• Adding scenarios, test data and screen shots used for testing to Test Ready User Stories in JIRA.
• Prepared and present weekly status reports to management
• Played active role during daily scrum meeting and task planning as part of agile methodology
• Interacted with offshore team to share & provide required information on planned work items for the sprint.
• Internal review of user stories with management for scenarios/test data/screen shots prior demo.
• Participated in Sprint Demo sessions with business.
• Performed Integration testing of ACMP application.
• Well versed with Microsoft SharePoint to manage project related documents.
• Involved in writing complex queries in SQL Server.
• Involved in Sprint retrospective meetings scheduled at the end of each sprint.
• Involved in UAT & SIT Concerns meetings.
• Involved in Planning & Product Backlog Grooming User Stories with Business Analyst and Team members.
• Participated in Defect Triage call to discuss open defects and Defect clarifications.
• Maintained Defect/Issues/Observations Tracking sheet.

Environment: SQL, HP Quality Center, Agile, ALM, Windows XP, MS Excel, MS word, VM ware, PBM.

Business Systems Analyst

Confidential, Abington, PA

Responsibilities:

• Performed gap analysis, requirements elicitation, joint application design/facilitation, process engineering, vendor management, data analysis, quality assurance & user training for practice management, billing and revenue cycle applications.
• Created Epics, user stories, business requirements documents and technical design deliverables, process flows, and mockups for all business applications.
• Business Analyst responsible for day to day production support and system maintenance of the GE practice management system including system enhancement and business rules configurations to ensure timely billing and reimbursement of claims.
• Optimized systems by partnering with end users and key stakeholders to identify, evaluate and develop cost effective systems and procedures which met user requirements.
• Systems integration analyst working as a subject matter expert for the GE applications working closely with other clinical and financial applications developers to define the interface specifications complete data mapping.
• Worked with cross functional teams including product vendors and internal development teams to finalize product requirements during the design phase and validate specifications during development/testing phases.
• Project lead utilizing scrum Agile methodology to manage user stories, product and sprint backlog using JIRA tool to define, assign, estimate effort each user story and associated tasks.
• Data analyst involved in claims and revenue cycle data analysis as assisting the business intelligence developers with data mapping and converting business requirements to technical data specifications.
• Reporting Analyst responsible for gathering reporting requirements from the business, developing reports in SQL, Adhoc reports and dashboards presenting reports to the business users.

Business Systems Analyst

Confidential

Responsibilities:

• Partner in PBM implementation in pre and post go-live testing.
• Prototype recommendations to facilitate meetings to derive business decisions for configuration.
• Responsible for validating the work performed within the various areas of the Configuration team
• Validation of Configuration Change Requests (CCRs) daily involving claims testing within QNXT
• Assists with the testing efforts required for the Annual Enrollment Period and 1/1 readiness (AEP)
• Often coordinate changes between the Configuration team and the specific requesting group Claims, PDM or Customer Services
• Participate in the UAT efforts for IT enhancement and break fix items as required by the IT change control process.
• Manages process improvement initiatives, seeking root cause and developing appropriate corrective action related to system configuration and claims.
• Administer UAT activities within the change control process for zero defect system configuration deployments, coordinate adequate product testing prior to implementation. Make recommendations to superiors regarding the acquisition and/or implementation of software changes.
• Interact with stake holders on requirement gathering.
• Ensure successful execution with JADS to collect and report requirements, perform data analysis/reconciliation.
• Review Quality Assurance Test Plans, Workflows and User Documentation to ensure correct interpretation of original specifications.
• Reviewed logical design documents and use cases and making sure the enhancements based on the Prescriptive authority changes with business team
• Microsoft SharePoint, RTM used to manage the project related deliverables to client and maintained internally for the audit purpose.
• Data mapping, logical data modeling, created Class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Performed GAP analysis for the modules in production, conducted feasibility study and performed impact analysis for proposed enhancements.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Performed Gap analysis and was involved in analysis of the technical specifications of the current system and the infrastructure needs.

Environment: Windows, Oracle, QNXT, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), MS Access, Agile, SQL, ETL, UML, Quality Center, and SharePoint.