SUMMARY:

• Over 8 year’s expertise in Business Analysis, Quality Assurance and Testing with hands on experience in Healthcare and Insurance Sectors.
• Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing.
• Skills include defining Project Scope, Business Process Analysis, Business Process Reengineering, Requirements Gathering, Data and Process Modeling
• Strong knowledge of the Software Development Life Cycle methodologies (phases and gates) like Agile and Waterfall models
• Experience with Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP), involved in inception, elaboration, construction & transition phases using rational tools like RequisitePro, ClearCase, ClearQuest during various phases of RUP.
• Single - handedly developed utility programs (using Base SAS & SAS Macros) for generic IND tables & Listings along with interface (SAS Macros - window
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278 code sets testing in Health Insurance.
• Extensive experience in Business Requirements gathering and writing skills with expertise in developing and documenting Business Requirement document (BRD), Functional Requirement Document (FRD),Software Requirement Specification (SRS) across the deliverables of a project.
• Effectively used Rational Requisite Pro to organize, track and change requirements of the system.
• Expertise in Data archival and Data migration, ad-hoc reporting and code utilizing SAS on UNIX and Windows Environments
• Expertise of UML in visualizing and documenting the artifacts using Use Cases, Use Case Diagrams, Activity diagrams, Class diagrams, Data Flow Diagrams, Business Flow Diagrams, Sequence Diagrams using MS Visio
• Expertise in producing RTF, PDF, HTML files using SAS ODS facility.
• Experience in facilitating Joint Application Development (JAD) sessions, Rapid application development (RAD) sessions, conducting user interviews and acting as a liaison between the customers, development team and testing team

TECHNICAL SKILLS:

UML Tools: MS Visio

Requirement Mgmt Tools: Requisite Pro, Clear Case/ Clear Quest

Testing Tools: Quality Center, Test Director, Win Runner, QTP, Load Runner

Databases: Oracle, Microsoft SQL Server, DB2, MS Access

Languages: JAVA, J2EE, SQL, PL/SQL, .NET, Java Script, VB Script, C, C++

Web Technologies: HTML,DHTML, CSS, XML

Operating Systems: Windows XP/2003 Server/NT, UNIX

Others / Reporting Tools: Microsoft Office Suite, Business Objects, Crystal Reports, Agile, RUP

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Business Analyst

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
• Designed the online screens and reports for the Medicaid Online Electronic Claims Submission System.
• Analyzed, designed, and coded several online subsystems for the Medicaid System.
• Gathered requirements for making changes to the existing Electronic Medical Records(EMR), Electronic Health Records(EHR) and Ambulatory Services for the existing Epic Interfaces.
• Responsible for business system analysis of customizing the BPS Risk Management product with involvement through the whole SDLC
• Develop automated network element capacity and utilization reporting using SAS, SQL and VBA.
• Participated in Bug-Review meetings with software developers, QA engineers, managers to check for 7 claims and suggested enhancements to the existed application from business perspectives and provided solutions to existing bugs.
• Worked on EDI X12 transaction set 837, 835, 270, 271, 277 feeds to allow change in the claim number.
• Well versed experience in all EDI transactions like 834, 837 P, 835, 27x and conversion of .
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements.
• Assist coders to be competent in using ICD-10-CMS/PCS
• Extensive use of MS Office tools like MS Access, MS Word, MS Excel, MS PowerPoint MS Project for data migration in to the CI System Knowledge Data Base in Microsoft SharePoint Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Involved in integration of various Customer Data Sources and provided Data Mapping from various sources like CCD, LPCD, DCD into the target centralized customer data source.
• Define and document EDI business process requirements.
• Monitor the flow of data through EDI applications to ensure all operational systems are functioning properly when needed.
• Migrated all EDI clients to Oracle operating system.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System ( Confidential )
• Involved in all phases of software development life cycle in RUP framework
• Develop SAS programs that employ multivariate regression analysis that will model, forecast and automate the utilization and capacity trends of new network elements as they're deployed.
• Evaluate requests for changes to existing HL7 interfaces; implications and impact of such changes in terms of other ongoing projects and resource requirements
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR(continuity of Care Record), CCD(Continuity of Care Document),NCPDP Script 8.1, ELINCS, and CDA
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Managed the transition to new development standards, procedures and processes including the introduction of UML, Rational Products including Rational Software Architect, ClearCase and ClearQuest as well as the Mercury Test Suite
• Developed detailed Developer specification to reflect technical details of the business requirements
• Performed data analysis by using SQL queries using the DB Artisan tool
• Worked on the HIPAA 4010 conversions and worked on the EDI 834, 837, 835 and 278 files and validated the functionality according to the new HIPAA 4010 changes.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Extensive experience in implementing Business Intelligence Techniques for FEPOC Reporting.
• Provided management support to the off-shore End to End Integration / Regression Test Team
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team
• Acted as a Subject Matter Expert on Application knowledge for preparing training presentation, Quick Reference Guides and assisting with any issues/questions that arose from training
• Involved in development of the system for data exchange from EMR, EHR to Electronic Lab Reporting Systems.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Worked with the Statisticians, Data Managers to provide SAS programming in analyzing Clinical Trial Data.
• 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) .
• Accomplished migration of EDI client base ahead of projected schedule.
• Managed various release cycles starting from enhancements to production for the RADAR application
• Provided production support on both SONAR and RADAR including any communications for the development team and to log defects/enhancements in order to plan future releases.

Environment: J2EE (JSP 1.1), EJB(2.0), Servlets 2.2, JMS, Java2 (JDK 1.3), STRUTS,JDBC2.0, XML, XSL, XSLT, Rational Rose, PL/SQL, HTML, CSS, JavaScript, Websphere4.0,Oracle 8.0, WebSphere Studio Application Developer v5.0, Win2000, Unix(AIX), MS Visio, MS SharePoint, MS Office.

Confidential, Cypress, CA

Sr Business Data Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Documented the business logic and associated validation logic.
• Met with various HMO, PPO, Medicaid/Medicare, and Tricare / Champus Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues
• 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
• Improved the new revenue cycle management and Electronic Medical Record (EMR) for PARTNERS.
• Created screen-mockups using iRise to review the requirements and provide feedback on the screen design. Also, used Microsoft Paint to create ad-hoc screen mock-up to review with the users.
• Documented and tracked requirements in Mercury Quality Center.
• Testing of HL7 Message Validation and sending of ADT Messages like ADT A01, ADT A04 and ADT A08.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Developed various forms of outputs like RTF, HTML, PDF files using SAS ODS facility.
• Worked on 837 (I, P, D), 834, 835, 820, 270, 271, 276, 277, 278 transactions and BRCs of the transactions
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• The HI-Exchange web portal features EMR functions and Integrated Clinical decision Support tools for better care management.
• Map flat files to X12 documents using ProEDI.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR(continuity of Care Record), CCD(Continuity of Care Document),NCPDP Script 8.1, ELINCS, and CDA
• Accomplished doubling of EDI client base ahead of projected schedule.
• Defined and clarified specifications for EDI software enhancements through communication with various departments
• Provided suggestions and ideas more from a strategic and long term perspective.
• Worked on the EDI 834 inbound and 834 outbound data movement with our trading partners
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Extensively worked with complex and huge datasets, and generated reports in various formats such as PDF, RTF, HTML and list files using SAS ODS facility.
• Created Requirements Specification Document that translated business requirements into Technical specification including business and validation logic for ease of understanding to the development team.
• Gather requirements and estimate effort for HL7 interfaces
• Accessed the data in SAS for the given requirement using SAS programming concepts.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Sound knowledge of Medicaid, Medicare Healthcare policies, benefits, plans and medical products and well-versed in EDI - HIPAA transaction code implementation - 834, 820, 837, 835, 276, 277, HL7 and experience working with member eligibility and enrollment modules and claims processing applications
• Designed and developed Use Cases using UML and Business Process Modelling.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Ensured that all Lines of Business specifications were consistent in form and function to the Diamond Base System.
• Involved in analysis for wide range of Six Sigma and Web-based initiatives, including user requirements.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Generated wireframes and prototype for the GUI.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Logged defects into QC while doing Functional Testing and followed through the process until the defects were closed.
• Reviewed the Defects entered by the QA team and prioritized the defects and assigned them to the development team
• Prepared UAT Materials, including the UAT Process, UAT Test document which would include step-by step process for UAT as well as all the tests that would cover all requirements.
• Interacted with the users and logged any defects, enhancements from the UAT.
• Worked with the Training Group to build training materials as well provided any suggestions/ tool tips to assist in User Training

Environment: Rational Rose and Requisite Pro, MS Visio, MS Access, MS Project, MS SharePoint, UML, XML, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9i.

Confidential

Data Analyst

Responsibilities:

• Helped in defining Change Management Process for Release Management Team.
• Mapped process flow; assess as-is processes through user interviews, data collection and analysis, design and evaluation of to-be process solutions.
• Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
• Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
• Technical Specification Creation for EDI. Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy.
• Assisted JAD sessions to identify the business flows and determine whether the EDI X12 Transaction, Code set and Identifier aspects of HIPAA, impacts any current or proposed systems.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Build, test and Deploy HL7 interfaces on Neon and Seebeyond Datagate interface engines
• Provide post go-live production support for HL7 interfaces
• Imported and Exported data files to and from SAS using Proc Import and Proc Export from Excel and various delimited text based data files such as .TXT (tab delimited) and .CSV (comma delimited) files into SAS datasets for analysis.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Identified gaps in the business process.
• Defined roles and responsibilities of participants in the business process.
• Developed and maintain information and documentation related to developing and modifying business processes and systems.
• Recommend system/process solution approaches to minimize risk and workflow impacts while capitalize strategic goals.
• Customized the test scripts using check points, synchronization and parameterization of data.
• Automation of test scripts was done using QTP for test re-usability of different online transaction modules.
• Gathered requirements from users of the Clear Quest (CQ) tool for any Enhancements or change requests for any defects.
• Involved in Six Sigma process analysis.
• Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and Use Case Narrative using the UML (Unified Modeling Language) methodologies.
• Led and conducted JAD sessions for requirements gathering, analysis and design of the system.
• Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using Rational tools.
• Designed and developed project document templates based on SDLC methodology
• Established RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
• Analyze business requirements and segregated them into Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and OOD using Borland Together according to UML methodology thus defining the Data Process Models.
• Documented Requirements for Management Reporting out of Clear Quest using Crystal Reports.
• Worked as a CQ administrator by assisting customer with any issues and by running queries for ad-hoc reports for management team.
• Facilitated Change Control Board and Governance Board meetings and acted as a liaison between parties impacted by the change requests.
• Provided training on new features within CQ and prepared training materials like Quick Reference Guides and Job aids.

Environment: Windows XP Professional, Oracle9i, MS Access 2000, MS Excel, MS Visio, MS Office, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.

Confidential, WI

Business Data Analyst

Responsibilities:

• Gathered legacy system requirements by shadowing Customer Service Representatives (CSRs), Customer Relationship Representatives (CRRs), preparing questionnaires, to identify limitations in the current system and GAPS in the proposed system.
• Created an enterprise workflow application based on CRUD rules for Customer Data that would allow for future integration of data infrastructure across various business areas into a single UI.
• Prepared logical data model in the form of Business Context diagram to include various entities and attributes in order to facilitate the design of Data model in the form of ER Diagrams. Studied current information structures and data models of the current databases to better understand the design of target data source.
• Used statistical analysis procedures in the generation of reports periodically for analyzing the business using SAS STAT procedures such as Regression Univariate, Correlation.
• Performed custom data conversions and developed custom software for risk management applications including general claims, vehicle accident and administrative tracking. Performed all data field mappings.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Used Rational Clear Quest to track required changes and Rational Clear Case to maintain different versions of the project documentation
• Designed workflows and allocated permissions within MS share point 2007.
• Modeled Business requirements into workflows to depict various scenarios of system to request RFI and RFP responses from major vendors.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Intricately involved in Business Process Flow development, Business Process Modeling, and ad hoc Analysis
• Performed detailed comparative analysis of response to RFPs of vendors and Graphically Represented the recommended solutions in PowerPoint to Senior Management
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Pega Business Process Management (BPM) tool.
• Conducted Requirements walk- through with the Business Team to ensure that all their needs are met and gathered sign off on the requirements for SOX compliance after the requirements were base lined.
• Prepared and maintain Business Rules Spreadsheets (BRS) identifying Rules, Triggers and corresponding data fields from Legacy to target CRM application.
• Followed a methodical Change Management Process and documented any Change Requests into Clear Case for any changes in the requirements after the requirements were base lined.
• Facilitated the User Acceptance Testing (UAT) with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
• Prepared training materials in the form of User manuals by preparing step-by-step guide to all screen flows in CMS.
• Assisted in development of User Interfaces and prepared screenshots to get business’s buy-in on the requirements.
• Worked with Siebel trainer to prepare training materials and conducted on-site training with Siebel to train the various types of audience like Customer Relationship Representatives (CRRs), administrators and Account Managers (AMs).

Environment: Requisite Pro, Rational Rose, Agile, HL7Interfaces, PL/SQL, HTML, MS Office, MS Visio, MS Access, EDI, UML.

Confidential, Deerfield, IL

Business/Data Analyst

Responsibilities:

• Created and maintained development plans that include As Is Work Flows, Functional specifications, Data Layouts, Use Case Modeling, Risk Assessment, Internal Workflows and External Workflow.
• Translated Business Requirements and user expectations into detailed specifications employing Unified Modeling Language (UML), MS Visio.
• Used Rational Tools for creating use cases, version control and defect tracking, monitoring. Use Rational Unified Process (RUP) methodology in all areas of the software development life cycle (SDLC).
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Liaison between developers and business users to communicate requirements for building third party interfaces.
• Performed all aspect of testing to ensure system changes are meeting identified business requirements.
• Developed and distribute necessary documentation required for releasing changes into the company’s production environment. Also, follow the software development life cycle and documentation standards.
• Created appropriate business work flows suitable for systems developers and users for project planning in the future.
• Conducted walkthroughs with the end users to gather the modification requests from the user to update or change the business specifications
• Conducted business process modeling and analysis; identified, assessed and articulated gaps/operational risks associated; presented risk-mitigation and operational enhancement solutions to project management team
• Used UML notations for Object Oriented Design and Documentation
• Developed prototype for auto quote processing system for QuickQuote, Full Quote and NewBusiness.
• Provided mapping of XML from Auto Web to policy management system.
• Integrated RequisitePro with ClearQuest and Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests
• 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)
• Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 278/278, 820, 834, 271U, 835, 837-(I, P, & D), 835 Remittances and others. Resource for UB04 and CMS1500 billing formats, transaction sets requirements, EDI development and Design, X12 protocols through Version 5010 and Errata; conversion needs and understanding of legacy EDI formats.
• Managed all the requirements in RequisitePro, making requirements available to all team members.
• Set up test environment to facilitate Test Plan.
• Used automated test tools (Win Runner) to verify functionality, predict system performance and test scalability prior to deployment.
• Conversion of data from different database environments, while performing Back End Testing.
• Responsible for executing Volume Testing, Compliance Testing, Data Quality Testing.
• Responsible for status check at regular timeframe.

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, Rational Requisite Pro, MS Office, MS Project, SQL Server, Agile, MS Project, MS Visio, MS FrontPage 2003, MS Access, EDI, Documentum 2.0.,UML