- Over 5+ years of diversified experience in Healthcare domain.
- Expertise in translating user requirements into System Specifications and mapping the process design, work flows for SDLC with documenting and managing business requirements.
- Worked on QNXT v 4.8, 5.0, 5.1 claims processing engine.
- Good experience in data sources, data profiling, data validation, developing low - level design patterns based on business and functional requirements. Knowledge of relational data modeling and relational database concepts.
- Good experience in developing work approach and project plans to meet client requirements, and manage and monitor progress.
- Experienced in developing functional and non-functional specifications, process diagrams, sequence diagrams, user interface designs and field level descriptions Experience in Creating Test Plan , Test Procedures and Test Metrics .
- Good experience working as Quality Analyst in Agile and Waterfall methodologies.
- Performed GAP analysis and maintained requirements traceability matrix (RTM).
- Experienced in conducting feasibility study and risk management.
- Worked on ICD 9 and ICD 10 and HIPAA 4010 and 5010 migration.
- Experienced in writing and reviewing test cases and test scripts Experience in backend data validation by writing SQL queries.
- Conducted usability and user acceptance testing (UAT) on behalf of end users.
- Experience in UNIX Shell Scripting and file manipulation techniques.
- Understanding of insurance policies like HMO and PPO.
- Experience with EDI transaction codes such as 270/271(inquire/response health care benefits), 834(Benefit enrollment), 835(Payment/remittance advice), 837(Health care claim).
- Familiar with Med claims billing services plan.
- Strong business analysis skills and thorough understanding of full SDLC
Business Methodology: RUP, Agile, Waterfall.
Business Modeling Tools: Microsoft Visio, Rational Rose.
Project Management Software: MS Project.
Version Control Systems: Rational Clear Case.
Testing tools: Test Director, Quality Center, Requisite Pro, and QTP.
Database: MS Access, SQL-Server, Oracle.
Sr Business Systems Analyst
- Collaborate with the Quality improvement team to oversee and ensure HEDIS data accuracy and abstractions including investigations, auditing, and improvement opportunities
- Develop and implement strategies related to data governance, data quality, metadata management, data security and master data management (MDM).
- Used Facets Claims and Member/Subscriber modules, and have worked on editing and validating claim.
- Manage and analyze clinical and non-clinical HEDIS measures such as comprehensive diabetic care, Human Papillomavirus Vaccine for Female Adolescents, Lead Screening in Children, Pharmacotherapy Management of COPD Exacerbation and Disease-Modifying Anti Rheumatic Drug Therapy for Rheumatoid Arthritis within Medicaid, Medicare and Commercial plans
- Implemented Master Data Management MDM for all entities in the project by maintaining a master hub for improving the data quality by following various data governance techniques and data dictionary standards.
- Requirements elicitation from Business. Prepared Business Requirements Documents (BRDs) and mapping specifications for MDM project.
- Retrieve data through table queries within Facets.
- Preventive Facets configuration, working closely with onsite physician for approval of preventive procedures.
- Develop road maps and provide expert consultation on improvement methods and strategies for audit purposes
- Collaborate with internal and external stakeholders to ensure HEDIS and CAHPS initiatives are fully integrated throughout the organization, maximizing opportunity to improve outcomes for members
- Perform detailed review of varied healthcare data to evaluate programs and product solutions using healthcare medical, pharmacy, lab and utilization data
- Monitor and ensure dataflow used by Medicare STARS department is accurate to ensure improvement of the overall STARS ratings for Medicare products
Environment: Oracle 12C, Teradata, Verisk Health (verscend) Software, Asana, DB2 10.5, Microsoft Excel, Microsoft Outlook, Microsoft One Note, Data Stage Designer Client
Confidential, Long Island, NY
Business System Analyst
- Identified the scope, business objective and documented the functional requirements for each release.
- Directly involved in process improvement Plans and implementing business change.
- Gathered requirements from Business Managers, Supervisors, stakeholders, Data Governance Team and the subject matter experts through meetings to understand needs of the system.
- Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and appropriate GUI screenshots.
- Set claims processing data for different FACETS Module.
- Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions
- Collaborated with Business and Data Governance to translate governance and business team needs into MDM Functional and Technical requirements.
- Extensively worked with Member/Subscriber and HIPAA Privacy Facets application groups.
- Involved in creating documents and diagrams for Membership Enrollment according to the HIPAA 834 Compliance Standards for Membership Enrollment.
- Set claim processing data for different Facets Module.
- Gathered requirements and developed process flows diagrams in accordance with care and Medicaid rules and regulations pertaining to the Facets configuration and evaluated the impact of proposed changes.
- Worked on Data Mapping to map Facets data to outbound eligibility extracts.
- Used Master Data Management (MDM) technology, tools to create and maintain consistent and accurate lists of Master.
- Created use cases specifications, use case diagrams, swim lane diagrams, component diagram and context diagrams to define the workflow and segregate high-level and low-level requirements using MS Visio.
- Conducted and Participated JAD sessions to gain consensus on various issues related to the project. Acted as a facilitator on different occasions.
- Held regular meetings with the Business users and SME’S to priorities the business Requirements.
- Facilitated the resolution of project-related issues, identified risks and mitigation steps to manage risk using PLSQL in RDBMS.
- Used Rational Requisite Pro for overall Requirements Management and to build the Requirements Traceability Matrix.
- Conducted walkthroughs and code reviews with developers, project managers and stakeholders and users to comprehend business work flow of applications.
Environment: Windows XP, RUP, UML, SQL, Rational Tools, MS Visio, Informatica, XML, MS Word, Excel, PowerPoint, Access
Confidential, Seattle, WA
Business System Analyst
- Conduct gap analysis between the current system and new requirements to be implemented thereby mapping the business requirements to the application
- Prepared high level and detailed system requirements documents for the application
- Identified the requirements for accommodating HIPAA 5010 standards for 837P transactions and captured these requirements to develop new GUI for the internet based application
- Set claim processing data for different Facets Module.
- Involved HIPAA regulations in Facets HIPAA privacy module
- Involved EDI Claim Process according to HIPAA compliance.
- Tested the Facets 4.3 and Claims processing applications
- Managed requirements using Quality Center
- Documented Test cases corresponding to business rules and other operating conditions in Quality Center
- Involved in Developing Test Plans, Test Cases and Test Scripts
- Performed End-to-End testing manually
- Responsible for GUI Testing, System Testing, Regression Testing and Acceptance Testing
- Tested the backend database using SQL queries
- Extensively worked with ANSI X12 HIPAA EDI Transactions 270, 271, 276, 277, 837, 835 and 997
- Involved in testing the Medical and Hospital claims in Facets based on Service, Agreement and Pricing Id's
- Tested the Web interfaces and Web Service Applications
- Worked with ANSI X12 (835, 837, 834) EDI Transactions
- Extensively used UNIX shell scripts
- Responsible in providing regular test reports to the management
- Reported the defects to the developers using Quality Center
Environment: Windows XP, Unix, RUP, Rational Rose, Facets, MS Visio, Information, HTML.