SUMMARY:

• Seven years of experience in business process analysis, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare, Insurance and Service Industry Sectors.
• 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 Business Process Modeling, Business Process Re - design and in designing Process Architecture.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
• Strong experience with different project methodologies including Agile, Scrum Methodology, SDLC, RUP.
• Extensive experience in gathering Business and Functional Requirements, Business Scope & Vision Document, developing Business Requirement document, Functional specification document, communication plan, Use Cases, conducting Gap Analysis and Risk Analysis.
• Worked on FACETS batches like XPF and MMS to upload bulk data into the FACETS system through the HIPAA gateway by generating keyword files to enroll, modify or terminate providers and members
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Knowledge of 837, 835, 277, 270, 271, NCPDP, 5010 and ICD-10.
• Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, Confidential -1500 claim forms and reimbursement forms.
• Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, Confidential -1500 claim forms and reimbursement forms.
• Experienced with insurance claims processing using main frame legacy system (on Oracle, MS SQL background) and paper intensive environment and experience in using Trizetto’s Facets e2 and Network X Suite for the membership eligibility, billing, claims processing and claims reporting.
• Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML), Object Modeling Technique (OMT), Extreme Programming (XP), and Object Oriented Analysis (OOA).
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Excellent understanding of Software Quality Assurance Techniques, CMM, Master Data Management, Six Sigma and ISO Standards and highly acquainted in working in SOX Compliance Environment.
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking
• Experienced with BI Reporting Tools like SAS, Databases like SQL, Oracle.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Defining Test Cases, analyzing bugs, interaction with team members in fixing errors and User Acceptance Testing (UAT)
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.

TECHNICAL SKILLS:

Project Management: MS-Project2010, MS-SharePoint Project Methodologies SDLC, Agile, Rational Unified Process (RUP), UML

Business Modeling Tools: Rational Rose, MS Visio

Requirement Management Tools: Rational RequisitePro, Rally

Defect Tracking Tools: Rational Clear Quest, Quality Center, Test Director

Operating Systems: Windows 7/XP/2000, UNIX

Database: Access, Oracle, SQL server, DB2, Teradata

Scripting Languages: HTML, CSS, XHTML,JAVA SCRIPT.

Quality Assurance: Software Application Testing Life Cycle

Business Applications: Microsoft Office Suite, MS VISIO, MS Project, SharePoint

Content Management Systems: Drupal, Joomla, Interwoven.

PROFESSIONAL EXPERIENCE:

Confidential, Washington DC

Data Analyst/Business Analyst

Responsibilities:

• Involved in Inception Phase and prepared vision statement and initial data models that contain Business Requirement Documents and supporting documents that contains the essential business elements and detailed definitions.
• Working with clients to better understand their needs and present solutions using structured SDLC approach.
• Accurate processing of Medicare claims using the Diamond system
• Gathered user and business requirements through open-ended discussions, brainstorming sessions and role-playing.
• Documented the user requirements Analyzed and prioritized them and converted them as system requirements that must be included while developing the software.
• Analyzed data and created class diagrams and ER diagrams for designing databases.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Suggested web security using encryption and authentication technologies for reporting and complaint filing procedures.
• Planned and defined Use Cases created Use Case diagrams, Scenarios and Use Case Narratives using the UML methodologies.
• Query optimization using SQL Profiler and performance monitors to enhance the performance of database servers.
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses (since Stored Procedures passes the whole block at one time.)
• Created Activity Diagrams, Sequence Diagrams and ER Diagrams.
• Created Mock-up forms in MS word for better visualization and understanding of the software solution.
• Identifying and modeling Use case diagrams, Sequence diagrams, Activity diagrams, Collaboration diagrams using UML.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Tracked change requests and monitored workload and schedule.
• Facilitated JAD sessions with management, development team, users and other stakeholders to refine functional requirements.
• Scheduled meetings with developers, System Analysts and testers to collaborate resource allocation and project completion.
• Created and managed project templates, use case templates, requirement types and tractability matrix in Requisite Pro.
• Managed workload, schedules and coordinated status review meetings with project managers, business managers and team members.
• Authored progress and completion reports which were then submitted to project management on a weekly basis in MS project.
• Identified various frequently used modules with in the application as well as the peak user volume for load testing purposes.
• Analyzed the test results from QA teams using Performance Studio Analysis to create various scenarios.
• Developed strategies with Quality Assurance group to implement Test Cases in Test manager for User Acceptance Testing.
• Collaborated with Quality Assurance Analyst in Automated and Manual Black box testing.
• Helped in creating end user manuals and procedure manuals.

Environment: Java, J2EE technology, Windows 2000 Advanced Server, Liberty,UNIX / Oracle Platform, MS Visio, RUP, UAT, Rational Rose 2002, Rational Clear Quest, Rational ClearCase, Rational requisite pro, rational test manager, Rational Robot.

Confidential, New Hudson, MI

Data Analyst/Business Analyst

Responsibilities:

• Interviewed Business Users to gather Requirements and analyzed the feasibility of their needs by coordinating with the project manager and technical lead.
• Collects requirements from department managers and users for enhancements. Acts as liason between clients and development. Facilitates sessions to bring business requirements and functionality into SAP system development and enhancement.
• Prepared Business Requirement Documents (BRD’s) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Worked on data modeling and produced data mapping and data definition documentation
• Configured the Data mapping between Oracle and SQL Server 2005.
• Tested Performance & Accuracy related queries under SQL Server
• Designed and implemented basic SQL queries for testing and report/data validation
• Created relationships in Requirement Traceability Matrix linking Business Requirements to Functional requirements and Functional Requirements to Systems Requirements.
• Conducted Joint Application Development (JAD) sessions with IT groups. Identified the Key Changes, and participated in Stakeholder Management to communicate effectively with them
• Developed and Documented timelines for Project Delivery, and managed Projects and Resources to successful completion.
• Used Data warehousing for Data Profiling to examine the data available in an existing database.
• Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using Microsoft Visio.
• Worked on Documentum for Version Controlling, to maintain up to date changes in the Documents.
• Assisted to develop the Test Plan, Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge.
• Conducted User Acceptance Testing, gathered and documented User Manuals and Business Rules

Environment: Microsoft Office Suite, Microsoft Visio, Documentum, Windows NT/XP, Oracle, SQL, SQL Server, Sybase, EVPN, IBM Websphere Business Process Modeller, ACORD, XML,Business Objects, TestDirector, LoadRunner

Confidential, El Paso, TX

Sr.Business EDI Analyst

Responsibilities:

• Conducted interviews with the Business Subject Matter Experts to gather, analyze, and document business system requirements
• Analyzed impacted programs to identify, understand and document business rules in plain language.
• Worked with Business SME’s and IT staff to identify and translate ICD business rules into system requirements.
• Implemented various HIPAA codes (270 and 276) used for Billing and Eligibility purposes of patient records.
• Reviewed technical impact analysis, identify and segregate relevant application code.
• Develop detailed specifications of X12 and XML data format standards.
• Knowledge of Medicaid Management Information Systems (MMIS).
• Supported the Confidential Medicare Part B program, Medi-Cal program, and Confidential of California by providing technical, analytical, testing, and implementation support to existing interfaces.
• Articulated and presented business analysis results clearly and concisely to IT staff.
• Developed requirements traceability matrix to be used in software development and QA testing.
• Identified required information fields and develop data dictionary.
• Participated in systems development efforts.
• Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS .
• Participated in testing, acceptance testing and implementation of information systems, modules and subsystems.
• Involved in performance testing of Medicaid client server claims processing system, Medicaid MCC / MCO and Medicaid Management Information System (MMIS).
• Establish and conduct monitoring activities centered on key Confidential audit findings and best practices including, but not limited to, formulary administration, point of sale edits, coverage, and claim reject reports.
• Experience with Medicare, Medicaid and commercial insurances in HIPAA, ANSI, X12 formats including 270/271, 276,277, 278, 835, 837, 997.
• Provided user support during application software implementations.
• Participated in Application Group and business unit meetings.
• Held training sessions for EPSDT, EDMS and RetroDur.
• Worked closely with Business Analyst and Developers to discuss test scenarios.
• Developed and documented test plan, set up test data to execute test steps, attended daily status checkpoint meetings, and also worked on change orders to understand the requirement.
• Extensively used Captiva to scan the documents and uploaded through FileNet to verify the attachment in EDMS panel through BPEL.
• Uploaded different files to verify the rejected claim location including Completion new and Completion Verify.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Worked on EPSDT claims to validate the YTD column, verified letters in AFP viewer and different reports in COLD by identifying appropriate recipients.
• Experience working on RetroDur with different kind of letter, surveys and created interventions.
• Worked on table change including adding, updating and deleting the field.
• Modified 271 file for map fix of warnings related message and EVSELIG program to accept a batch of eligibility requests from SACWIS.
• Experience submitting different kind of claims including LTC, Dental, Hospice, Inpatient, Inpatient crossover, Institutional and also overlapped claims to create EOBs.
• Extensively worked on financial process for submitted claims and created CPAO selection requests, Cost Settlement numbers and generated CPAO report to verify CS03, CS01, CS05 and CS07 calculation.
• Extensively worked on different form of Patient liability, TPL, RMF, Provider LTC Rates and setting up the data including Nursing facility care and ICFMR.
• Worked on Managed Care to add PMP assignments, verified PMP Assignment history panel, Case/Cat/Seq data, Benefit plans and also worked on 1061 and 1062 files to check the error code, descriptions.
• Created paper claims, XML (Electronic) claims and direct data entry claims for testing purposes
• Responsible for generating reports for batch processes in mainframe.
• Interacted with the DST (off shore) teams for QA support and training purposes. Responsible for running test region EDI loads on AS400 Series. Updated records in AS400 before processing for testing purposes.
• Ran claims batch loads in AS400. Wrote SQL queries to for Data Mining and Data manipulation in MHS. Used HP Quality Center for reporting and tracking defects.
• Research in design methods to create scenarios for adequate test coverage.
• Performed database validation in the Mainframe to ensure the data entered through the front end reached the database.
• Created reports using Mercury Interactive Test Director

Environment: HQ Quality Center, SQL, XML, IBM Mainframe, ALM QC, IBM AS400 iSeries, Win 2000/XP, MS Excel, SharePoint, PDS (Project Deliver System), HIPAA.