SUMMARY:

• Qualified professional with 8 years of extensive experience in the field of Business Analyst working with the technical staff to implement management and staff's business requirements into the software application in Healthcare domain.
• Expertise in documenting the Business Requirements Document (BRD), Technical Requirement Document (TRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Good experience in the EDI transactions and knowledge on EDI transaction process flows.
• Strong experience and understanding of health care industry, claims management process, Knowledge of Medicaid and Medicare Services.
• Working experience for Dental, Professional and Institutional Claims
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Used Rational Clear Case for Version Control of requirement documents.
• Experience with TriZettos Facets Application Groups/ Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Good knowledge of Workflows and Content Management Tools.
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and UML concepts.
• FACETS version upgrade implementation project and worked extensively on 837i (Institutional Claim), 837p (Professional Claims), 837D (Dental) and 834 (Enrollments).
• Experienced in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound 834Membership Enrollment, 837Institutional, 837Professional, 837 Dental, 835 Claim Payment/Remittance Advise, 270/271 Eligibility Benefit Inquiry/Response, 276/277 Claim Status Inquiry/Response Transactions and testing in Client Server systems and Mainframe Applications.
• Worked with different Business Areas like Claims and Enrollment to document proposed ICD 9 - 10 Code changes.
• Knowledge and expertise in working with Claims, Provider, Enrollment, Finance, Benefits, and Vendor Management Business Areas.
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD/Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases

TECHNICAL SKILLS:

Project Methodologies: SDLC, RUP, UML, Agile, Waterfall

Business Modeling Tools: Microsoft Visio, Rational Rose

Healthcare Tools: EDI X12, HIPAA, 4010, 5010, Trizetto, FACETS, ICD 9/10

Testing tools: Mercury Quality CenterChange Management Tools Rational Clear Quest

Office Tools: MS Project, MS Office, MS Visio

Version Control Systems: Rational Clear Case

Database: MS SQL Server, MS Access, and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Bronx, NY

Sr. Business System Analyst

Responsibilities:

• Ensured all artifacts complied with HIPAA 5010 policies and guidelines.
• Formulated and defined systems scope and objectives through research, data mining, analytics and fact-finding.
• GAP Analysis: Analyzed the client’s applications programs to determine the impact of the HIPAA final rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance
• Created ETL documentation such as EDI X12 837(P,I), 834 and 835 Data Mapping, Transformation logic for Main Frame Layout, Updating Meta data documents for new Platform.
• Creating and validating data using SAS functions and procedures.
• Systems Documentation included Business Requirements Document (BRD), Systems Requirement Specification (SRS) and test plans using Requisite Pro.
• SME for Oracle Letter generation based on the HIPAA guidelines involved in protecting the patients information
• Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Worked on project migration of all Healthcare Process (such as EAB, Products, Provider, Claims, Capitation, Voucher, finance etc) for Dental HMO from Legacy system (AREV) to Facets.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Re-engineered and captured EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Perform the comparison between ICD 9 and ICD 10 codes and defined the complexity in ICD10 codes remediation.
• Gathered requirements from the clients and developed crosswalks for 820, 834, 835, 837 P/I claims.
• Performed Gap Analysis between current and future state of application changes based on ICD 9/10 remediation.
• Worked with vendors to ensure their systems have ICD 10 codes and compatible with our internal claims processing systems.
• Analyzed plan requirements and then contributed further defining the plan requirements with their Project Manager. Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements.
• Working experience for Dental, Professional and Institutional Claims (UBO4 and 837D, 837P & 837I).
• Integrated Requisite Pro with Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
• Supported technical team members for technologies such as SSAS, Microsoft Excel and SQL server.
• Involved in writing complex SQL queries to check the data integrity.
• Analyzing User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Involved in the complete business process redesign and reengineering effort in converting existing process into a strategic web based environment.
• Used SOAP UI, Web Logic Server 11 ANT task to test Web Services running on Web Logic Server11
• Performed extensive data modeling to differentiate between the OLTP and Data Warehouse data models.
• Worked on Facets Claims Processing for data validation and claims validation. Extensively worked on Claims Inquiry and Dental Claims Processing.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Analyzed EDI transactions in XML and X12 responses.
• Identified Member, Provider, Coverage, Medicare, and Medicaid.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.
• Identified Actors, Activities, Artifacts and Workflows and developed use case diagrams using Rational Rose.
• Developed reports using SQL in MS SQL Server environment
• Run automated ruby scripts on a UNIX/LINUX machine.
• Re-Organized the collected data and prepared documentation for implementation.
• Created Activity Diagrams, Sequence Diagrams and ER Diagrams
• Worked with relational databases, and developed PL/SQL queries to interact with Databases.
• Planned the UAT testing, test plans, test cases and worked with the business users for UAT test execution in developing the training documentation.
• Experience in relational databases (RDBMS) like Oracle, SQL, and MS Access.
• Coordinated with business, design, development, and test teams, facilitating client engagement and meeting with BizTalk, completing performance reporting and status calls.

Environment: MS Visio, Word, Excel, UML, Facets, PowerPoint, Rational Requisite.

Confidential, Long Beach, CA

Business Systems Analyst

Responsibilities:

• Gathered business requirements through discussion with stakeholders and SME’s.
• Performed Gap Analysis for HIPAA 5010.
• Involved in activities to make sure proper documentation and standards are being followed.
• Wrote Business Requirement Document after collecting requirements through conducting interviews, JAD Sessions and brain storming sessions.
• Generated test data using X12 generator for transactions 270/271, 276/277, 820, 834, 835, 837P/I/D . Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Developed use case Designed process flow diagrams using MS-Visio and also Business Context Diagrams.
• Created Data Mapping to document to migrate data from the existing system to the new system.
• Strong Documentation and Report Generation skill and experience by Use case approach.
• Participated in software upgrades for claims work flow and EDI transactions (835,278) upgraded from Version .
• Worked extensively on EDI transactions 837 and 835 Involved in writing test cases for different LOB’s (ITS, FEP And Regular) for SIT, Parallel and UAT.
• Did Presentations making Stakeholders understand how the changes would affect different modules w.r.t. Medicare and Medicaid.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Documented, organized and tracked the requirements using Rational Requisite Pro.
• Conducted User Acceptance Testing (UAT) prior to and after implementation phase.
• Worked on conversion from ICD-9 to ICD-10 with respect to the claims related to Medicare (Part A, Part B, Part C, Part D).
• Mapped EDI 834 transaction to BCBS LA enrollment/eligibility system to comply with State of Los Angeles Health Care Reform Project. Ensured accurate enrollment data for health plan products across multiple systems.
• Assisted developers in trouble shooting and resolving EDI issues by collaborating with internal and external business partners to define business processes and information requirements by building on intermodal industry best practices and ANSI X12EDI standards.
• Used FACETS 4.71: Subscriber/Member, Medical Plan to validate the Eligibility benefits received in the 271 response.
• Executed Test cases manually by composing 270, 276,837 EDI files and dropped inbound and check response 271,277,835 using interleaves and outbound.
• Performed parallel testing for the 83xtransactions to ensure comparable results between 4010 and 5010 transaction processing with the help of XC file comparisons, Keyword file comparisons and other significant file structures with end-to-end testing cycle Analyzed and provided compare results for production XC’s (External Claims) and test XC’s for all LOB’s after every build to validate if the defect were fixed.
• Used SQL Queries to verify the data from the Sybase database.
• Involved in Up-gradation of HIPAA X12 4010 transactions to HIPAA X12 5010 and ICD-9-CM to ICD-10.
• Used Edifecs Transaction Management tool to verify that the batch and real-time files are generated correctly.
• Used the iLink Blue Provider Suite to test that the 270/271 eligibility requests and responses and the 276/277
• Assisted in upgrading HMO Medicare EDI and reporting.
• Claim status Request and Response are generated according to the 5010 format. Validated the same.
• Creating and consolidating SIT Test Cases and UAT test Cases using MS Excel or Quality Center.
• Was involved in working with the offshore testing team to co-ordinate Regression Testing.
• Preparing sample Test Data and executing Test cases using Quality center.
• Provide support to end users while execution of UAT with proper test scenarios & test data.
• Monitored RTM to close the defects/cases as and when developers resolved the defects
• Communicated with developers and Business Analysts through all phases of testing to prioritize defect resolution.
• Reporting the Test Execution status to the project manager on daily basis.
• Performed System Integration and Regression Testing for the Microsoft BizTalk 2002 applications . These are developed to perform Electronic Data Interchange (EDI) translation from ANSI (ASC) (American National Standards Committee) ASC(Accredited Standards Committee) ANSI (ASC) - X12 layout to MMIS fixed-width record format.
• Actively involved in weekly walkthrough meetings and Daily Defect calls to verify the status of the testing efforts meeting the deadlines & mid-term targets

Environment: M S Vi si o, E d ifecs Tran sa ctio n M an ag em ent, iLin k Blu e P ro v id er Su ite, M i cro s o ft SQL S erv e r, Qua lity C enter, IB M D B2, Syb a se, M S W o rd and M S Exc el

Confidential, New York, NY

Business Analyst

Responsibilities:

• Involved in gathering and creating functional and non-functional requirement documents, IRD’s, Use Cases, Wire Frames, end to end system work flows, interface diagrams, mapping documents, presentations, message specifications, test scripts for enrolling and maintaining groups and individuals.
• Created architecture Solution flows, UML diagrams, service charters and detailed message specifications for development of messages/interfaces which using Business Process Modeling Notations (BPMN).
• Created Requirements Traceability Matrix and support in creation of enterprise solution architecture to integrate business rules across domains.
• Assisted in the development of the RFC tool (manages the change process from project inception to release).
• Responsible for creating and maintaining documentation related to the project including scope document, vision document, functional specification document, defect status report, mitigation plans, supplementary requirements specification document and impact analysis document.
• Extensively worked on preparing the test plan and test cases for EDI transaction like 837, 834, 835, 270/271, 276/277, 278.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions related to providers, payers, subscribers and other related entities.
• Understanding of, and experience with, server-client computing and relational database environments
• Worked on Claims (Dental, Medical, and Rx), Customer services, Members, Enrolment interfaces and extensions for FACETS as a part of FACETS implementation team.
• Conducted process mapping to identify current As-Is business processes and To-Be road map for reengineering the products.
• Participated in changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Validated 835, 837, 276, 277, Institutional and Professional HIPAA Transaction and X12 format messages.
• Performed Database testing using DB2 Connect and Extra tools for verification of data tables in database.
• Involved in the full 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), 997 and 999 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Involved in activities to make sure proper documentation and standards are being followed.
• Implemented automated COB processing of Medicare claims into Facets
• Extensively worked on Data Migration from Informatica to SQL- SSIS
• Strong visual modeling and business process modeling skills in Rational Unified Process (RUP) and Agile Modeling with tools like Rational Rose, MS Visio.
• Maintained daily SQL (SSIS, SSRS) reporting, ad-hoc reporting
• Extensively created Business Process Modeling Diagrams/Swim Lane Flows using BPMN notations and MS Visio indicating transformations and feeds.
• Created crosswalks to support list of values across enterprise for reusability and for supporting CDM.
• Performed extensive GAP analysis and created Message Specification Documents for service calls.
• Developed Customer Service Inquiry chart for Dental and Vision providers. Wrote Use Cases, prepared use case diagrams (using Rational Rose) and followed Rational Unified Process at every stage of the process.
• Performed Data Profiling and Data Quality.
• Used ERwin for data modeling.
• Extensively involved in Data Extraction, Transformation and Loading (ETL process) from Source to target systems using Informatica Power Center.
• Worked closely with lead Data Warehouse developers to evaluate impact on current implementation, redesign of all ETL logic
• Debugged SQL queries as a reengineering process to any problems or errors found.
• Responsible for Data Extraction, Data Compilation, Data Analysis, Data Manipulation and Data Validation using SQL queries in a MS SQL Server 2005 environment
• Experience in relational databases (RDBMS) like Oracle, SQL, and MS Access.
• Involved in extracting the data from various source systems like Sybase, DB2, Oracle and flat files and loaded to a relational data warehouse and flat filesR
• Generated XML documents using the XML Output Stage.
• Attended implementation calls and provide coordination on calls and acquiring RFC's.

Environment: Windows, MS Office (Excel), MS Visio, FACETS, SharePoint, BPMN, SSIS

Confidential, Raleigh, NC

Business Analyst/EDI Analyst

Responsibilities:

• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus for BRD and FRD and business docs.
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
• Acted as a liaison and conducted meetings, JAD sessions and presentations with the teams
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) and 820) standards
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Eligibility.
• Worked in ANSI x12 EDI Transaction.
• Worked on HIPAA Standard/Gstandard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 to identify key data set elements for designated record set. Interacted with Eligibility, Payments and Enrollment hence analyzing and documenting related business processes.
• Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions include 837, 835, 276, 277 (both inbound and outbound) transactions
• Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with Use Cases from the analysis.
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Documented the dimensional models of ETL system.
• Worked on Audit/Edits reconciliation for claims codes to correct any configuration and documentation inaccuracies and updated Audit, Edit and Claim Check Manuals as required.
• Designed and created SQL Databases tables, indexes, and views, User Defined Functions, Stored Procedures and Triggers based on user requirements.
• Assisted in Regression Test, System Test, and UAT.

Environment: Microsoft SharePoint, MS Visio, MS Office, HP Quality Center 10.0, Toad for Oracle, Team Track, AGILE methodology, COGNOS

Confidential, Boston, MA

Business System Analyst

Responsibilities:

• Performed stakeholder analysis to identify key players for project success.
• Identified and involved all key stakeholders, contributors, and technical resources that must participate in a project and ensured that contributors are motivated to complete assigned tasks within the parameters of the project plan.
• Played an active and lead role in Gathering, Analyzing, and writing Business Requirements.
• Followed Agile Development methodology throughout SDLC.
• Collected and documented business and operations processes as well as business rules. Provided key input in working with users in defining project and system requirements.
• Translated the Business Requirements into Functional Requirements and communicated with the business users on a non-technical level.
• Established, documented, and maintained EDI procedures. Tasks include identifying errors and taking corrective action, reconciling EDI transactions through coordinating information with internal and external customers, and working closely with internal departments and external vendors to maintain EDI integrity.
• Involved in gathering requirements, configuration, and data conversion of the Facets application modules like Enrollment, Membership and Claim.
• Documented the System Specifications Document.
• Created and maintained Dashboard and the Requirements Traceability Matrix (RTM).
• Created Use Cases, and Use Case Diagrams and through understanding of Business Process Modeling.
• Interacted with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Conducted JAD and RAD sessions as needed.
• Ensured Use Cases were consistent as well as covered all aspects of the Requirements document.
• Designed and developed scenarios based on Business Requirements.
• Created and managed Project Templates and Used Case Project Templates.
• Worked on Unix Platform and experienced in back end testing by executing SQL Queries.
• Checked the data flow through the front end to backend and using SQL Queries to extract the data from the database.
• Carried out User Acceptance Testing (UAT).
• Conducted reviews with all the stakeholders and Subject Matter Experts to ensure that the Requirements meet their needs.
• Performed Integration and Regression Testing along with testers.
• Assisted with Test Cases and developed strategies with Quality Assurance group to implement them.
• Efficiently responded to client inquiries and resolved discrepancies.
• Collaborated with Quality Assurance Analysts to track defects.
• Maintained Repository for Requirements documents.
• Consolidated status reports of the team for the Project manager.

Environment: Windows NT Server, SQL, Oracle, Web Logic, IIS, EDI