SUMMARY:

• Senior business analyst with 7+ years of industry wide experience in various domains with solid understanding of Business Requirement elicitation techniques, Business Requirements Gathering, Business Process Flow and Business Process Modeling.
• Comprehensive knowledge of software development methodologies such as Waterfall, RAD, RUP and AGILE SCRUM.
• Adept at preparing Business requirements documents (BRDs), Functional requirements documents (FRDs), defining project plans and delivering project reports.
• Experience in SDLC, Agile, Waterfall, Rational Unified Process, and SCRUM software development methodologies.
• Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.
• Lead and worked with teams to examine and solve business problems by accurately analyzing the needs of clients and helping them achieve improved quality and value for their customers, strong leadership and mentoring skills, and highly proficient organizational and computer skills.
• Working knowledge and good understanding of PBM (Pharmacy Benefits Management) application
• In depth knowledge of RUP's Iterative Software Development Life Cycle (SDLC) process, Agile Software Development and Waterfall models.
• Experience with health care systems: QNXT, FACETS, Medicare Part A, B, C, D, Medicaid systems, and validating General Equivalency Mappings (GEMs), Technical Report Type 3 (TR3) Implementation Guide, and Companion Guide.
• In - depth knowledge of Healthcare organization operations including outsourced operations, Health Insurance, HIPAA, and Medicaid/MMIS, including MITA.
• Gathered requirements to check HIPPA- eligible & participation check for individual coverage.
• Technical and business knowledge in multiple disciplines/processes.
• Strong understanding of HIPAA Transactions & Code Sets Standards like (820- Premium Payment for enrolled health plan members, 834- Enrolment /Disenrollment to a health plan,
• Extensively worked with different X12 Hierarchical Levels (HL structures) in various inbound claim/inquiry-response transactions (837 P/I/D, 270/271, 276/277).
• Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets
• Worked on development and implementation of policies, procedures and QA methodologies
• Experience in developing Test Plans, Test Scenarios and Test Cases based on functional requirements.
• Plan, Design and implement application database code objects, such as tables, stored procedures, user defined functions, triggers, SQL, packages, cursor & schedulers etc. in windows environment.
• SQL query optimization and tuning by choosing proper access plan.
• Build SQL scripts, indexes and complex queries for analysis, extraction & creation of data on client server.
• Experience in executing Test Cases to test the application functionality against the requirements manually.
• Excellent skills in Business Analysis, OO Analysis, Data Analysis, Requirement Analysis, Business Modeling and Use Case Development using UML methodology, Project Management Methodologies include RUP, SDLC, and Waterfall.
• Excellent communication and presentation skills. Experience working with business user as well as senior management

TECHNICAL SKILLS:

Operating Systems: Windows XP/NT /2000/98, UNIX, Linux

Languages: C, C++, Java, Basic, HTML, DHTML, Visual Basic 5.0/6.0

Packages: MS-Visio, MS- Project 2000, SharePoint 2007, Rational Suite, MS Office

RDBMS MS: - Access, Oracle 8i/8.x and SQL Server

WORK EXPERIENCE:

Confidential, TX

Business Analyst

Responsibilities:

• Responsible for the development and implementation of HIPAA EDI Data Mapping artifacts 270, 271, 274, 276, 277, 820, 834, 835, 837 and 5010.
• Performed User Accepdatatance Testing for the ANSI X12 Version 5010 / EDI transactions (HIPAA) for Claims Status and Eligibility (270, 271, 276, 277, 834, 837P, 837I, 837D, 835 remittances and NCPDP Claims).
• Developed HL7 messaging for bi-directional case and disease report exchange, in HTML and XML formats, in accordance with HL7 specifications.
• Developed crucial functional requirement specifications, creating detailed use cases and process flow diagrams to support functional specifications and put in Version One tool.
• 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.
• Facilitated and/or supported all Scrum Events, Sprint Planning, Daily Scrum, Sprint Review and Sprint Retrospective.
• 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.
• Created high level user story/tasks in the JIRA, initiating the implementation of the migration project.
• 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.
• Working experience with Rx-PBM domain.
• Involved in giving KT to the new member of the team.
• Performed Integration testing of ACMP application.
• Well versed with Microsoft SharePoint to manage project related documents.
• Visualization of KPIs using Tableau and Power BI.
• Provide knowledge, skills, work processes, best practices, and tools to enable effective functional analytics and visualization.
• Involved in writing complex queries in SQL Server.
• Involved in Functional Design review meetings.
• Participated in daily offshore & onsite meetings on daily task assignments.
• Involved in Sprint retrospective meetings scheduled at the end of each sprint.
• Coordinated with team members to share work items based on the priority and completed in timely manner
• Maintained good relationship with in the team and was active team member
• Involved in UAT & SIT Concerns meetings.
• Developed web applications using AngularJS, JQuery, JavaScript and CSS.
• Created graphical user interfaces (GUIs) front-end using JSP, JavaScript, JQuery&HTML5
• Managed the planning and test process for Medicare Pharmacy Claims (PBM).
• Prepare client ready deliverables for senior peer review and present to clients. Prepare, seek peer review for, and deliver client ready PBM and product deliverables to marketplace clients along with marketplace Consultants.
• Involved in Planning & Product Backlog Grooming User Stories with Business Analyst and Team members.
• Assessed the Scrum Maturity of the team and organization and coaching the team to higher levels of maturity, at a pace that is sustainable and comfortable for the team and organization.
• Participated in Defect Triage call to discuss open defects and Defect clarifications.
• Research and resolve complex issues relating to claims adjudication, eligibility verification, prior authorization and other Pharmacy Benefits Management (PBM) processes.
• Business Analyst lead for the Provider Data Integrity project. The objective of the project was to clean up any data issues in Amisys and HPN before migration to QNXT
• Maintained Defect/Issues/Observations Tracking sheet.
• Implemented multiple data collection strategies that optimized reporting for HEDIS measures.

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

Confidential, Bloomfield CT

Business Analyst

Responsibilities:

• Analyze 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.
• Spearheaded client implementation and integration projects for Medicare's Chronic Care Management (CCM), working directly with EMR and EHR vendors and end users at physician practices. Heavy focus on HIPAA, HL7, C-CDA, Web Services, SOA, scalability and performance.
• 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.
• Gathered requirements, developed Process Model and detailed Business Policies.
• 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.
• Created documents to address simple work efforts that required less than 80 hours of design and testing before implementation to address new business requests.
• Configure 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).
• Managed PDP discovery project on Pharmacy Benefit Management (PBM), Fraud.
• Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM (Health Trans) and Claims Accumulation and Adjudication is done
• Utilize Member module to verify eligibility, benefits and PCP assignment to maintain accuracy.
• Update and analyze Claims 101 edit errors for missing contracts in an accurate and timely manner to avoid penalties.
• Ensure system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
• Involve in Post Implementation phase of the first release of migration, tracking the bugs through JIRA on regular basis, and re-prioritizing the issues in daily scrum calls with business.
• Played a key role during Analyzing, preparing technical and functional design specification documents as per the Requirements, Architecture, Development and Maintenance of high traffic application built in Java/J2EE.
• Worked on various Web forms using HTML, CSS, Bootstrap and JavaScript, React.JS.
• 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.
• Organized Agile team using Scrum Methodology (daily standup, retrospect, burn down rate, velocity) and utilized Rally for capturing epic stories, user stories and managing iteration schedule.
• Pharmacy Benefits Manager (PBM) services experience including integrated accumulators, claim processing, enrollment, drug utilization, prior authorization and customer center applications.
• Provide analysis and conduct testing for change requests, software releases, and fixes.
• Support Data Migration, Parameterization, IT - Sub Projects, To Be Processes and Training streams with their activities, and provide inputs as and when required.
• Oversee and implement submission of HEDIS/STARS and Encounter data to contracted health plans.
• Ensure departmental documentation, daily and weekly reporting is being completed timely and accurately.

Environment: SQL Server, Windows XP, Informatica, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, MS Visio, MS Project, Java, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML.

Confidential

Business Systems Analyst

Responsibilities:

• Worked as a liaison between the business client and development team for the implementation of 4010 to 5010 transition in compliance with HIPAA standards.
• Involved in the 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) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Identified the business functions and processes, and prepared system scope and objectives based on user needs and industry regulations.
• Defined terms, conducted stakeholder analysis, elicited business needs, conducted business process modeling, and facilitated JAD sessions. Elicited, documented requirements and use cases. Analyzed, validated & prioritized requirements; traced requirements to related project documentation (process models, designs, test scenarios & scripts).
• Documented the Requirements and circulated them to Business & Technical teams for Signoffs.
• Coordinated with the developer and testers for transition of EDI X12 4010 series to 5010 series. Maintained traceability through updates to the Requirement Traceability Matrix (RTM) using Requisite Pro.
• Collaborated with the business team in the creation and completion of project charters and project scope for Guidewire Policy Center and Claim Center. Collaborated with the business team in the creation and completion of project charters and project scope for Guidewire Policy Center and Claim Center.
• Identified gaps in existing Policy Administrating Systems and Guidewire Policy Center and diligently designed as-is and to-be process, in scope and out of scope documents.
• Worked closely with manager to analyze & understand Business requirements; gathered User, Functional and Non-Functional requirements & translated the requirements into User Stories for Scrum process using Rally.
• Identified testing scenarios and defined Test Cases for detailed functional testing.
• Involved in forward mapping of ICD 9 to ICD 10 and backward mapping of ICD 10 to ICD 9 using General Equivalence Mappings (GEM).
• Developed a Schedule and identified project milestones.
• Analyzed business scenarios to track possible business outcomes for the functions which could be incorporated into more detailed test scripts.
• Reported project progress to the team, senior management and all stakeholders periodically.
• Identified risk and project impact and performed risk assessment and mitigation.

Environment: SQL, MS Word, Excel, Access, Oracle, DB2,Guidewire, Lotus Notes, File Viewer, Web Client, Clear Quest, Requisite Pro, GEM, MS Visio, SharePoint.

Confidential, Roanoke, VA

Business Analyst

Responsibilities:

• Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
• Created Use-Cases and Requirements documents to document business needs.
• Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts and other potential users of the application.
• Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
• Created and maintained the Requirements Traceability Matrix (RTM).
• Worked on Guidewire, extensively worked on Guidewire Policy center & Guidewire Claim Center
• Used GuideWire software to track the claims of the policyholders.
• Guidewire was specifically used by the team to implement the enhancement to expedite the claim process for unregistered users
• Used Guidewire to upgrade the current Claim system to track the claim of the policyholders and third party applications
• Involved with the testing team to check the augmentations done previously using Guidewire.
• Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
• Maintained documents and the effect of proposed changes on the project schedule and costs.
• Used Rational Clear Quest for bug reporting.
• Documented the Use Cases and Activity diagram worked on COTS Integration and Application Architecture design. Created and maintained workflow plans and business process flows using MS Visio 2013.
• Worked directly with software engineers to ensure clear communications on requirements and defect reports.
• Designed and developed scenarios based on business requirements.
• Developed requirements integrating E-R diagrams and designed the testing process flows.
• Followed the RUP methodology for the entire SDLC.
• Used the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of the Software Development Life Cycle.
• Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated the scripts to make sure they have been executed correctly and meets the scenario description.

Environment: Windows2000, Rational Rose, Guidewire, Rational Unified Process, Rational Clear Quest, Oracle, and Microsoft Project 2000.