SUMMARY:

• Qualified professional with more than seven years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Health & Welfare and Healthcare Industry.
• Experienced in Facets working with Provider Life cycle, Members Enrollment process and other data models.
• Experienced in complete SDLC, Client /server architecture providing a well balanced understanding of business relationships, business requirements, worked for financial and technical solutions and help the team at all levels until final product release.
• Experienced in MS Office Suite, MS Visio, iRise and gathering user requirements and technical documentation.
• Responsible for EDI strategies enabling Health Care Providers and Insurance Careers to communicate effectively. Good Working Knowledge of HIPAA Regulations and Claims Processing.
• Experience configuring QNXT applications for case management, flexi conversion, provider, member, member eligibility, and prior authorization.
• Proficient in all aspects of QNXT configuration including eligibility and enrolment, provider reimbursement and network management, referral and authorizations, claims processing, and premium billing and accounting.
• Extensive knowledge in Claims processing system, Medicare, Medicaid, managed care, Health Plan, provider, membership, enrollment, ICD 10, Health Information exchange (Affordable care act), PBM (Pharmacy Benefit Management) and Data warehouse.
• Strong experience interviewing senior level company officials to gather requirements for documenting project functional specification.
• Gathering Functional Specs/Requirements between Upper Management and Technical Engineers
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Organized Joint Application Developments (JAD) sessions and Joint Requirement Planning sessions (JRP), walkthrough, Interviews, Workshops and Rapid Application Development (RAD) sessions with end - user/clients/stake holders and the IT group.
• Expertise at requirement analysis, requirement prioritizing and developing the Business requirement documents (BRD), functional specification, High Level Diagram, and Low Level Diagram.
• Proficient in using UML in behavioural, structural and architectural modeling - in creating Use Cases, State, Activity, Class and Sequence diagrams.
• Expertise in Creating User Stories, test scenarios, release plans for XP methodologies
• Good hands on experience testing of inquiry screens to support EDI transactions.
• Expert in team leading, project management and requirements management
• Accountable for leading the business analysis portion of the project plan in collaboration with the project manager
• Extensively worked on all phases of Data Warehousing project like Data Cleansing, Data modeling for data staging & Data Mart, ETL, Indexing, Quality Assurance, Data updating plan, and Data presentation to business users.
• Analyze business processes, identify and propose new business processes or program changes to address specific requirements
• Ability to develop, write and maintain gap analysis, business requirements and technical documentation
• Good Communicator, Team Participation skills, Leadership qualities, Analytical skills

TECHNICAL SKILLS:

DISCIPLINES: Project Planning, Scope Development & Management, Requirements Elaboration, Business Intelligence, Data Warehousing, SQL, GAP Analysis, User Training, Business Process Analysis & Research, Technical and Business Use Cases, Medicaid, Medicare, UI Design/ Wire Frames, Process Flow Diagrams, Test Planning & Execution, Business Process Reengineering, Requirements Traceability, Data Analysis, User Acceptance Testing (UAT)

Methodologies: Rational Unified Process (RUP), JAD Facilitation, Waterfall Methodology, Software Development Lifecycle (SDLC), Agile Methodology, SCRUM Methodology, Unified Modeling Language (UML)

Tools/ Softwares: Microsoft SharePoint, Microsoft BI Stack, Microsoft Dashboard Designer, Microsoft SQL Server 2005, 2008, Report Portal, ANSI X12, HIPAA EDI, EMR, Trizetto QNXT, Facets, ICD9/10, Enrolment/Claims, Excel Services, Quality Centre, MS Project, MS Office Suite, MS Visio, MS OneNote, Java, Oracle, JavaScript, UNIX.

PROFESSIONAL EXPERIENCE:

Confidential, Boise, ID

Business Analyst

Responsibilities:

• Worked in implementing various areas in QNXT for Case Management, Flexi conversion, Provider, Member, Member Eligibility and Prior Authorization.
• Involved in analyzing the Transformation rules and updating the Data Mapping Document (DMD) with the transformation logic.
• Designed, wrote, tested and implemented processes for daily or monthly interface imports and exports for Member and Eligibility.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Working with subject matter experts and program managers to translate business requirements into functional and technical requirements.
• Establish Test/Development to Production Export/Import EDI Transport from AS/400 to UNIX and assist in transition from legacy system(s).
• Documented the code steps and reviewed the selection criteria code for an interface. Created the Technical notes, run book and layout for the interface files.
• Responsible for creating and updating File Mapping Documents, Technical Notes specification document.
• Developed standardized FACET testing, involved in implementation and QA process. Worked on FACETS Claims Adjudication, Claims Pre-pricing and Claims Logging.
• Involved in complete system development life cycle (SDLC). Documenting conversion requirements and participating in their development (design, construction, testing and roll out).
• Served as liaison between company and vendor product support in order to prioritize and resolve issues
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Coordinated front-end changes in multiple development and testing environments
• Created data files to be loaded to the Target QNXT system and reviewed and corrected error reports.
• Worked towards delivering a first draft solution to ETL team for coding as soon as the requirements changed.
• Wrote and executed several SQL validation queries for validating the data converted from source to HealthPAS database for conversion validation, testing and reviewing the data using MS SQL Server 2005.
• Validated test plan results that satisfy the detailed design goals.
• Wrote test cases for the QNXT model areas of Case Management, Flexi conversion, provider, member, Member eligibility, Prior Authorization.
• Supported Unit Testing, System Integration Testing, System Testing, User Acceptance Testing.
• Updated the DMD after the project implementation with the updated/changed requirements, as questions were resolved.
• Updated technical specification/mappings and supported the ETL developers requiring the mappings created.

Environment: QNXT, RUP, Quality Center, Oracle, UML, MS Visio, XML, ETL, MS Project, MS Excel, MS SharePoint, MS SQL Server, .Net, iRise, Rational Rose.

Confidential, PA

Business Analyst

Responsibilities:

• Conducted JAD sessions with Subject Matter Experts (SME's).
• Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
• Designed High level design, for New process, integrating with legacy and Facets
• Did Presentations making Stakeholders understand how the changes would affect different modules with respect to Medicare and Medicaid.
• Performed Gap analysis for better understanding of transition from HIPAA 4010 to HIPAA 5010 inside trizetto QNXT different modules.
• Revised HCFA-1500 and MCS-1500 forms with stakeholders.
• Created system use cases, activity diagrams, mapping documents, work flows, screen shots and PowerPoint presentations using Requisite pro, MS Visio and MS Office suite.
• Worked on changes for HIPAA Transaction and proposed changes to be made in the current system for an easy transition from version .
• Documented the detailed business as well as technical requirements to upgrade the current system to 5010 transactions.
• Conducted User Acceptance Testing (UAT) prior to and after implementation phase.
• Got involved in designing future state processes for HIPAA 5010 transaction processing EDI's 834, 837,835, 270, and 271.
• Analyzed HIPAA 5010 related to 834, 835, 837, 270, 271, 276 and 277 transactions (both inbound and outbound) and performed gap analysis between the 4010 and 5010.
• Worked on ICD conversion from 9 to 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.
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Played a key role in planning UAT and implementation of system enhancements and data migration and conversions.
• Integrated Requisite Pro with Rational Rose to provide all teams visibility and maintains tractability among requirements, use cases and change requests.
• Completed a review of existing documentation for orders, referrals and reports and compared it to the clinical details needed for ICD-10.
• Assisted in writing test case scenarios for unit testing, integration testing and compliance testing.
• Involved with ICD10 implementation testing.
• Assist end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS.
• Conducted QNXT backend database analysis relating to finance module for internal/external reporting purposes.

Environment: UML, MS SQL Server, Client-Server, Web-Server, SQL*PLUS, RUP, Rational Requisite Pro, EDI, Quality Center, Trizetto QNXT, Facets.

Confidential, New York, NY

BA Analyst

Responsibilities:

• Developed strategic plan documents and project management policies.
• Processed insurance claims through the Preferred Provider Organization (PPO).
• Developed standardized FACET testing, involved in implementation and QA process. Worked on FACETS Claims Adjudication, Claims Pre-pricing and Claims Logging.
• Used General Equivalence Mappings (GEM) to convert ICD 9 to ICD 10.
• Used Rational Rose for data modeling. Conducted Joint Application Development (JAD) sessions to develop an architectural solution that the application meets the business requirements, resolve open issues and change requests.
• Completed time estimates for all technical items, assigned work, monitored developers’ progress and produced timely status reports for upper management.
• RUP methodology and documented the requirements using Rational Requisite Pro.
• Worked with 276/277 EDI transactions where exchange is used.
• Worked with the SME’s to define business critical needs and analyzed the possible technical solutions.
• Prepared and perform testing on Algorithm of PPO plans for large group exchange standard products
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) documents, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Conducted joint requirements planning (JRP) sessions as a facilitator to gather requirements from the business area and to discuss different critical success factors.
• Worked on HL7 to provide framework to carry electronic transfer.

Environment: Rational Suite (Rose, Requisite Pro), Windows XP/2000, SQL, XML, HTTP, MS-Project, MS-Office Suite, MS Visio, Test Director (Mercury Interactive), Java, Oracle, RUP, XML, UML, Agile., Crystal Reports, Adobe Acrobat, PL-SQL, Oracle 9i, SDL

Confidential, Helena, MT

Business Analyst

Responsibilities:

• Identified and documented impact areas, systems, interfaces, layouts for remediation of the Medicaid management system.
• Responsible for Detail system design documents which identified impacted areas and detailed logic to address issues arising due to the introduction of NPI number in all system processes.
• Conducted JAD sessions, Video conferencing and coordinated offshore operations with developers to meet deadlines.
• Performed GAP Analysis. Developed Project schedules, conducted project status meetings and managed resources during all phases of the SDLC
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analysing and documenting related business processes.
• Developed software validation guidelines to meet client needs and comply with government requirements.
• Used documentation tools such as MS Office, MS Visio and MS Excel to document and deliver Business Requirement documents to the state for approval.
• Gathered business Requirements, analyzed data. Created work flow diagrams and identified scope creep. Progressed from problem statement to well-documented Designs for state approval and for production, and implementation.
• Identified and defined technical specifications in liaison with the development team for system design, coding and testing.
• Prepared and maintained status report, charted out schedules, allocated and managed technical and human resources using MS Excel and MS Project.
• Defined core business rules and validations for the entire project and established change control procedures.
• Coordinated and documented maintenance procedures in liaison with the production team and established procedures and defined regions and procedures for future maintenance work.
• Assisted in writing test case scenarios for unit testing, integration testing and compliance testing.
• Participated in the planning and execution of the User Acceptance Testing effort