SUMMARY:

• 8+ years of Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollment and eligibility processes.
• Good functional knowledge of HIPAA regulations, ANSI X12, 4010A and 5010 standards& working knowledge of HL-7 message standards, support and maintenance.
• Complete knowledge of registration, scheduling and billing processes for Revenue Cycle and Patient flow.
• Excellent knowledge of E-Commerce, healthcare IT along with HIPAA regulations, EDI transaction Code Sets, and CMS regulations.
• Firm ability to research, analyze and translate complex business and technical information to stakeholders, SMEs, and developers at all levels of the organization. Also, in Defining, Gathering, Documenting, and Managing requirements to identify the real business need of the client company.
• Excellent communication, interpersonal consulting and facilitation skills.
• Working expertise in Software Development Life cycle (SDLC), Project Life cycle, Business Process Modeling (BPM), Software Development Methodologies including Rational Unified Process (RUP), Waterfall, Spiral, and Agile with SCRUM process
• Organized in Joint Application Development (JAD) and Rapid Application Development (RAD) sessions with business/end users, expert team and technical team.
• Experience on working with the Trizetto FACETS 4.31, 4.51, 4.71Data models.
• Significant Testing Experience in ASC X12 EDI for HIPAA and electronic healthcare transactions such as 270/271, 274, 276/277, 278, 820, 834, 835, 837 for Version 5010.
• Developed use case diagrams, sequence diagrams, state diagrams and activity diagrams, business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML).
• Experience in producing documents like Business Requirements Documents (BRD), Functional Requirement Documents (FRD), Software Requirement Specifications (SRS), Creating Request for Proposals (RFP), creating Requirements Traceability Matrix (RTM)
• Experience in creating Prototypes and Wire frames and documenting them using MS Visio and Enterprise Architect
• Involved in all phases of Testing life cycles including integration testing, User Acceptance testing (UAT) Functional testing/Black Box Testing, Regression testing, GUI testing, and performance testing.
• Hands on experience with Object Oriented Analysis and Design (OOAD); work side by side with technical managers; senior design engineers/ analysts; used UML extensively with emphasis on Use Case diagrams, state diagrams, sequence diagrams, activity diagrams and collaboration diagrams using Rational Rose and MS-Visio; solid hand-on experience working with MS Excel, writing very complex Excel macros to pull data in Data Mining and Data Warehousing environment; help in designing the ETL processes.
• Excellent verbal and written communication skills with interpersonal and analytical skills
• Demonstrated ability to adapt into new environments, learn new skills and participate/lead teams.
• Acquainted with SQL, Quality Center, Quick Test Pro, Win Runner and load Runner.
• Gathering business requirements for ICD 10 Groupings/ classes pertaining to maintenance process, ICD 10 business rules remediation process, Medical Claims Processing System (MCPS)
• Creative and aggressive self-starter and a versatile team player with excellent analytical, problem-solving capability for collecting clear and detailed Business Requirements and Functional Specifications.
• Team player, hardworking, highly self-motivated, fast-learner and goal-oriented individual committed in pursuing a long-term career in Information and Communication Technology.
• Strong analytical skills, resourceful problem solver with ability to work under pressure
• Experience in working with cross-functional/ cross-cultural groups.

TECHNICAL SKILLS:

Methodologies Agile, Waterfall, RUP, UML, SDLC, Scrum, RUP, V-shape modeling: Change Management Tools Rational Clear Quest, Rational Clear Case

Business Modeling & Versioning Tools MS Visio, Visual Paradigm, Rational Rose; Rational Requisite Pro, Rational Clear Case: MS Office MS Project, MS Word, MS Excel, MS PowerPoint, MS Access, Infopath Designer

Programming Languages Structured Query Language (SQL): Operating System Windows NT/98/2000/XP

Databases Access, Oracle 8i/9i/10g, Teradata V2R5.1, DB2, MS SQL Server 7.0/2000: Other known tools Informatica, Load Runner, Win Runner, Crystal Ball, Expert Choice, Core, Caliber

OLAP Tools Business Objects XI, Cognos: Testing toolsRational Robot, Rational Clear Quest Test Manager, HP Quality Center, Quick Test Professional (QTP), LoadRunner, WinRunner Apps & Webservers Apache web server, Tomcat, Web logic 8.1, IIS.

PROFESSIONAL EXPERIENCE:

Confidential, Austin, TX

Business System Analyst

Responsibilities:

• Perform a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
• Have strong experience in requirements gathering by conducting interviews with end users
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact
• Assisted with training of associates on small enhancement processes; worked with ACES claims data for claims subject area, Enrollment and billing data for membership subject area
• Conducting business validations covering the following deliverables: Facets Providers, Facets Claims and Facets Membership areas
• Reviewed extensive SQL Queries with complex multi-table joins and nested queries.
• Experienced with BI Reporting Tools like SAS, Databases like SQL, Oracle.
• Managed the entire UAT set up & UAT testing effort with the Business users.
• Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
• Carried out a thorough target organization assessment and risk analysis.
• Experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, and FACETS 4.5/4.7 system, Claims Processing, Insurance Pricing and Claim Adjudication. Strong Experience in FEP (Federal Employment Program) and CDA (Clinical Development Analytics) . Healthcare Domain Knowledge with SQL knowledge (in Oracle environment) and 5010, ICD-10 experience.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS Visio.
• Designed and implemented basic SQL queries for QA testing and report / data validation.
• Worked with the clients on the final signing process in the User Acceptance stages.
• Mapped the collected data with the existing data provided by the hospital departments.
• Used Word, Excel and Visio as a working tool.
• Involved in reviewing complex SQL queries, views, functions and stored procedures and spotting issues before/during code migration.
• Hands-on experience and good understanding of the hospital working system including Registration, Scheduling, Radiology, Laboratory, Pharmacy, Patient Accounting, HIM, Claim Processing etc.
• Met the deadlines and scheduled day to day meeting sessions

Environment: Facets, Oracle, HIPAA, EDI, Mainframe, XML, SharePoint, MS Word, MS Excel.

Confidential, NYC, NY

Systems Analyst

Roles and Responsibilities:

• Assisted in the Project manager in creating and updating the Vision Document, Business case, and the Project Plan to define Objective, Scope and Risks. Also assisted in creating RUP iteration plans and phase plans
• Generated test cases in Claims Analyzer Editor Professional to ensure unification with CPT-4 and ICD-9 codes
• Elicited requirements, and managed Change Configuration to maintain an orderly procedure for managing requirement changes after sign off
• Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
• Followed AGILE methodology viz. Scrum throughout the project.
• Involved in gap analysis and implementation of HIPAA 5010, ICD10 and Claim Validations
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health Insurance.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Configured FACETS.to adhere to customers work flow for claims processing, claims automation and group administration
• Used FACETS to provide seamless transactions between the provider, members and the plan and used FACETS Workflow to route the claims according to the priority.
• Worked on Value added routines in Facets and provider and subscriber modules
• Experience with BlueCross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12, 4010 and 5010 ICD9 and ICD-10 implementation guidelines & electronic formats including 270/271, 276/277, 700, 701, 810, 820, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications including NEIC, SSI, ESI, Datatrac, Medtrac, Cube, BlueCross, Medicare, and several others using COBOL, Metafile, Visual Basic, Unix, DOS, Assembler, C, FTP, Windows, Novell, and various other communication packages.
• Created Heat map with alert mechanism. Various KPI graphs were drawn. Kept eye on Qlikview best practice
• Project entailed developing a data model based on MS SQL Server and Tableau Server.
• Worked as Subject Matter Expert (SME) for various projects. Taught the users to get along with Qlikview.
• Elicited functional specifications, conducted feasibility analysis, and performed impact analysis
• Elicited Business Rules and other Non-functional specifications for the new system by interviewing the Subject Matter Experts (Doctors & Nurses) to further understand the business models
• Analyzed CMS comparison documentation highlighting changes of 5010 format and ICD10 diagnosis and procedure codes.
• Authored functional specifications for different HL7 system interfaces: ADT (registration), SIU (scheduling), OMG (rad order entry), and ORP/RDS (Rx processing)
• Designed, developed, and implemented innovative & sustainable Tableau reports. Supported effective rollout of reports, including training collateral
• Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997
• 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).
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
• Responsible for positioning and delivering QlikView projects and cross building applications into new and existing customer base
• Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Gathered requirements from the clients and developed crosswalks for 277/288, 834, 835, 837 P/I claims
• Developed test cases based on the crosswalks and compliance guidelines for 277/288, 834, 835, 837 Professional, Institutional and Dental claims and for 270/271 eligibility benefit inquiry and response
• Created Use Case Model using Rational Rose for developers and other stakeholders to understand the business process, depict roles, and procedures
• 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.
• Coordinated daily activities with the IT Developers, QA and Product teams along with the project management group.
• Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data
• Generated test data using X12 generator for transactions 277/288, 834, 835, 837P/I/D. Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
• Created Online User Guide comprising different scenarios, screenshots, and troubleshooting procedures

Environment: Rational Suite (Rose, RequisitePro, Requisite Web), Rational Unified Process (RUP), Informatica, facets, Windows XP/2000, Doors, Oracle, IBM WebSphere, SQL, System Architect, MS-Project, MS-Office Suite, MS Visio, MS Word, MS Excel

Confidential - Groton, CT

Business Analyst

Responsibilities:

• Understood and articulated business requirements from user interviews and then converted requirements into system requirements.
• Designed and developed business flow diagrams, wireframes, mock ups, user interface design, activity diagrams, sequence diagrams, Object Oriented models using MS Visio.
• Conducted JAD sessions with end user community ensuring that the software addressed all business needs, analysis of the potential users of the system either through discussion.
• Clarified client requirements, business needs and project objectives, via feedback sessions and client meetings, in collaboration with all stakeholders.
• Collaborated with Sales and Marketing teams, external ad agencies, third-party technology distributors to facilitate communication for successful project launches.
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Responsible for converting the programs from version for HIPPA standards, there was also included the NCPDP 5.1 conversion for drug claims.
• Assisted Design Team in preparing SSR, Software Design Document (SDD), User Interface Design, Application Architecture and Database Modeling
• Create, develop and manage content for organization's web presence (requires working with content management software)
• Strategized project scoping and specifications documents, logical data model, to clearly communicate the project roadmap.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables
• Met with all developers, offshore team and project stakeholders to lead a kickoff meeting. Defined and introduced the project, team members' roles, and key deliverables. Mapped out timelines, milestones, communication processes, question and answer session.
• Generated excitement and buy-in to secure commitment to project objectives, and shared a group vision to start the team on a motivated track

Environment: MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio, BIE), MS-Project, Windows 2000, OBIEE, Business Objects, SharePoint, Epic, Adobe CS3, Microsoft EDW, MS SharePoint, Six Sigma, .Net 4.0, RUP, Agile, SDLC, TFS, Microsoft Test Manager, People Soft.