SUMMARY

• Around 6 years of experience in business analysis, business requirements modeling and development of Web Based, and Client/Server applications extensively in business domain of Healthcare.
• Solid Experience in Business Requirement Management (Elicitation, Validation, Specification, Verification), Gap Analysis, Business Process Modeling, Process Management, Change Management, and Application Development, in Healthcare Domain.
• Full understanding of Rational Unified Process (RUP) using Rational Rose Modeler, Rational Requisite Pro, Unified Modeling Language (UML) in the context of Water fall methodology and Agile Methodology - SCRUM.
• Experienced in areas of writing Business Requirements Document (BRD), Functional Specifications Document (FSD), System Requirement Specifications (SRS), and design and development of use case scenarios.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Expertise in performing GAP analysis and Impact analysis driving internal and external requirements and conducting SWOT analysis, Risk analysis and Cost/Benefit analysis.
• Functional knowledge in developing and implementing Claim Processing Systems.
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278 code sets testing in Health Insurance.
• Participated in source to target and Data warehouse analysis on a regular basis
• Working expertise in Workflows and UML diagrams such as Use case diagrams, Activity diagrams, Sequence diagrams and Class diagrams.
• Expertise in Problem solving and Bug Tracking Reports using Bug tracking Tools
• Experience in designing Test Strategies, Test Cases, and Test Scripts and conducting User Acceptance Testing (UAT).
• Strong technical skills in SQL to extract data from the database for data analysis and testing.
• Actively involved in creating User Manuals and highly experienced in Post Production Validation (PPV) and Production Support.
• Experienced in working with various departmental teams, developing interactive relationships with business and IT colleagues, having a thorough understanding of needs, and perspectives of both the business users and the technical team.
• Efficient Team player, energetic, result-oriented, fast learner, excellent communication skills with strong research capabilities.

TECHNICAL SKILLS:

Requirement Management Tools: Power Designer, Rotational Rose, Rational Suite Enterprise, MS Visio

Methodologies: Agile, Waterfall, RUP (Rational Unified Process)

Defect Tracking Tools: Jira, Bugzilla, Load Runner

Databases: SQL, MS Access, Oracle

Operating Systems: Windows, Unix, MAC OS

Reporting Tools: Business Objects

PROFESSIONAL EXPERIENCE

Confidential, Springfield, IL

Business analyst

Responsibilities:

• Gathered requirements from stakeholders for provider management and member management.
• Analyzing all aspects of the existing business practices and procedures to facilitate effective cross-department communications, identify and resolve issues, coordinate system requirements, and create project timelines
• Prepared the Business Requirement Document BRD and functional requirement document FRD for the enhancement of the existing services.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Involved working with the HIPPA-EDI ANSI X12 Transaction Code sets
• Analyze, modify and create EDI 837
• Involved in validating system changes made under the Hospital Rate Reform
• Involved in writing and validating test scenarios for transition from ICD -9 to ICD-10
• Involved in identifying, testing and documenting changes required for Revenue Line Expansion project
• Worked with ICD10 codes to implement in MMIS for HIPAA 5010 Claims.
• Analytical understanding of EAPG grouping system in regards to both electronic and UB04 claims
• Design Use Cases using UML and managed the entire functional requirements life cycle.
• Developed GAP analysis between new cloud system and the old legacy claim system
• Developed a solution report to address the gap between the two systems
• Worked validating data that was migrated into the new system
• Oversaw processing and preparation of new and revalidated provider enrollment in IMPACT system.
• Facilitate functional and user acceptance testing (UAT)
• Prepared reports for team efficiency using SQL.
• Maintained agile boards/charts and performance related metrics in JIRA
• Analyzed and restructured business rules to maintain legacy system while transitioning into new cloud based system

Environment: MS Word, MS Excel, SQL, Jira, UAT, Visio, Mobius, 3M EAPG Grouper, Ultra Edit, MMIS, Bi Query

Confidential, Buffalo, NY

Business Systems Analyst

Responsibilities:

• Gathered requirements from stakeholders for provider management and member management.
• Identified and validated business rules and data elements.
• Created 837(P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837(P, I, D), 835, 270/271, 276/277 and 278.
• Modeled the ‘as-is’ process flow and the ‘to-be’ process flow and analyzed the gap and developed the action steps to fill the gaps.
• Analyze EDI - X12 data elements captured by the existing system to validate it against the data elements required for new system.
• Worked with legacy team in developing BRD for multiple system change requests and participated in system testing.
• Worked within project team to identify and interpret state Medicaid policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Conducted Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
• Developed BPMN flows in VISIO and documented User Stories
• Facilitated meetings with the technical team and client team to analyze the current process and gather requirements for the proposed process.
• Assist the HEDIS Supervisor in coordination of the Medical Record Review Project.
• Created functional requirement specification documents such as UML diagram, use case diagram, scenarios, activity diagrams and mapping.
• Developed the User Interface (UI) prototypes to capture and validate requirements and spike solutions to the current problem.
• Created Logical/physical Data Model in ERwin and have worked on loading the tables in the Data Warehouse
• Identified, researched, investigated, analyzed, defined and documented business processes and Use Case Scenarios.
• Analyzed requirements for developing a cross-walk for understanding major changes from ICD-9 to ICD-10 with the help of SME’s.
• Facilitated JAD sessions for Requirement Validation with Dept. of Cleveland clinic to gather requirements for the new MMIS.
• Built relationships with the ACO Participants to help communicate the yearly changes in HEDIS Measures.
• Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
• Examine the system design deliverables & validating it against the SLA.
• Contact provider offices and members to retrieve Medical Records for both HEDIS and Risk Adjustment
• Developed UAT test cases associated with the functional requirements.
• Used Facets to receive inbound transactions and 834 inbound files

Environment: MS Office, Windows, .NET, Agile, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Facets, Oracle, SOA, HTML, BPMN.

Confidential, Austin, TX

Business Analyst

Responsibilities:

• Used Requisite Pro for the Requirement Documents Preparation and 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.
• Medical Claims experience in Process Documentation, Analysis and Implementations in 835/837, 270, 276/277processes or Medical Claims Industry from the Provider/Payer side
• Involved in HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Accepted inbound transactions from multiple sources using FACETS
• Identified gaps and performed gap analysis with respect to CMS requirements
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Analyzed CMS comparison documentation highlighting changes of ICD10 diagnosis and procedure codes.
• Assisted with project planning, requirements development and completing ad hoc change management activities.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Documented the Traceability Matrix for tracing the Test Cases and requirements related to them.
• Performed Unit Testing and User Acceptance testing and documented detailed results.
• Provided input (scope, goals, risks, constraints, timelines and interfaces) to PM for project planning and control.
• Played a substantial role in the process definitions and business and functional requirements gathering, in an effort to develop a practical technology solution for automating sales methodology.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams, and Collaboration Diagrams thus defining the Data Process Model and Business Process Model.
• Responsibility included creation, member enrollment, billing, letter generation, contract administration and claim adjudication.
• Created workflow scenarios, designed new process flows diagrams and documented the Business Process and various Business Scenarios and activities of the Business from the conceptual to procedural level.
• Met with various HMO, PPO, Medicaid/Medicare Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues
• Participates in scheduled meetings with HEDIS team, vendors and HEDIS auditors
• Used Facets to receive 834 inbound files and processing of the files across different modules in the application
• Collected business requirements to set rules for proper data transfer from Data Source to Data Target in Data Mapping.
• Developed business process models in RUP to document existing and future business processes.
• Prepared Demo on SharePoint for various Business to get new approvals like the Therapist and Nursing divisions.
• Used Quality Centre to track required changes and Quality Centre to maintain different versions of the project documentation.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Created business process workflow diagrams using Business Process Modeling Notation (BPMN)
• Developed Test Plans and Test Cases according to Business Requirements.
• Acted as User Acceptance Testing coordinator and monitored business testing and interfaced with the development team regarding defect status and fixes daily.
• Involved in generation and execution of SQL queries.

Environment: SQL, HP Quality Center, Facets, Share Point, MS Office, UML, Rational Rose, Windows, MS Visio, MS Project, BPMN