- BUSINESS ANALYST with 8+ years of hands on experience in business consulting and application development with excellent skills in client interfacing, requirement gathering, user support, problem solving, and documentation.
- Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them.
- Knowledge of Health exchanges: off marketplace exchange and on marketplace exchange. Federally Facilitated marketplace, state partnership Marketplace, State based marketplace.
- Proficient in identifying, documenting and analyzing Business Requirements Specifications (BRS), System Design Specifications (SDS) and Software Requirement Specification (SRS).
- Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes, Claims Process, Health information Exchange (HIE), Electronic Health Record (EHR) and Electronic Medical Record (EMR).
- Specialized experience in healthcare insurance domain including Medicare and Medicaid. Profound experience with HIPPA X12 EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim - status), 834(Benefit-enrollment), 835(Payment/remittance advice), 837(Health care claim).
- Experienced in gathering requirements for HIPAA EDI Transactions (837,834, 835,270,271) in various phases of implementation.
- Experience in conversion and mapping of HIPAA X12 4010 codes to X12 5010 codes and ICD 9 codes to ICD 10 codes.
- Strong knowledge of FACETS and actively involved in end-to-end implementation of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
- Proficient in Requirement Engineering Process, including gathering, analyzing, detailing and tracking requirements
- Experience in interacting with stakeholders like business clients, end users, vendors, SDLC team, configuration manager and production team to identify information needs and initiate process change.
- Expertise in creating various artifacts like BRDs, Functional Specs, Used Cases, UML Diagrams, Data Mapping Documents, Test Plans and Test Strategies, pre and post RTMs and Status Weekly Reports etc.
- Strong visual modeling and business process modeling skills using Rational Unified Process (RUP) with tools like Rational Rose, and MS Visio.
- Expertise in using various tools like RequisitePro and Ms Office for requirement gathering, Quality Centre and Clear Quest for Defect Management/Defect Tracking, MS-Visio for UML Diagrams, Ms Outlook, IBM Lotus Notes and SharePoint for information sharing.
- Effectively used various elicitation techniques to gather requirements like JAD sessions, brainstorming, prototyping, one and one sessions, workshops, surveys, interviews and conferences.
- Hands on experience in the complete Quality Assurance (QA) life cycle from Requirements Gathering and Documentations to developing Test Plan, Test Cases, Traceability matrices and conducting User Acceptance Testing (UAT) for QA Testing.
- Experienced in writing SQL queries to extract data using complex inner joins, outer joins, constraints etc.
- Worked with PMO to review time line and schedule for the implementation and discussing the milestone.
- Excellent analytical, organizational, communication and documentation skills along with good process management skill to gather requirements to bring out the quality product.
- Motivated self-starter, good team member with exceptional team building, leadership, and interpersonal skills to resolve issues.
Project Methodologies: Rational Unified Process (RUP), Waterfall, Agile, Spiral, SCRUM
Business Modeling Tools: Rational Rose, MS Visio, Rational Clear Case
Requirement Management Tools: Rational Requisite Pro
Defect Tracking Tools: Rational Clear Quest, Quick Test Professional, Quality Center
RDBMS: Oracle, SQL Server, IBM DB2
Languages: Visual Basic, XML
Business Applications: FACETS, MS Access, Excel, Outlook, PowerPoint, Visio and SharePoint
Version Control Systems: Rational Clear Case
Operating System: Windows, UNIX/Linux
Confidential, Maclean, Virginia
- Understood and Implemented Form 1095-A Data elements Deep Dive document (BRD) that explains the project scope, project deliverable, common reasons for known data errors on form 1095-A and limitations of the 1095-A project for coverage 2014.
- Recognized the reference materials like FFM Marketplace Issuer Data Extract File layout (Mapping document) created for Issuer Pre-Audit Enrollment file to analyze the data elements of Pre-audit Data file for case resolution.
- Realized and followed the Form 1095-A Issue workflow processes to better understand analyst roles and responsibilities within the project.
- Being able to adapt and work efficiently in an agile environment where the cumulative Standard Operative Procedure (CSOP) and Policy directives and decision Matrix documents were in process and unstable during the initial phase of the project.
- Attended and participated in daily Team call and Managerial Meeting to update the Case status of various Case types and gave walkthrough on complex cases during Peer Review session with Peer Review Team and escalated the cases through Team manager regarding Policy directive and guidance for case resolution.
- Followed and adhered to the standard policy directive to research and request MIDAS, EDBO and Pre-Audit Data files which contain PHI of consumers to resolve the issue on 1095-A forms.
- Worked as a Subject Matter Expert (SME) and Mentor to other Analysts to identify and analyze the real issues on consumer’s 1095-A form and helped them in case resolution following CSOP.
- Communicated effectively with different roles: Data miners issuer, Outreach team and Consumer Outreach Team and special project Team members in the process of case resolution and case escalation throughout the project.
- Implemented and used OneNote (MS office product) effectively within our Team as a cross- platform for daily updates of work load priority, changes in Policy directive and team collaboration to resolve any issues with complex cases among Team members before any issues were escalated to RO (regional Office of CMS) and upper management for guidance.
- Adhered to the latest Decision Matrix versions as it gets reviewed and updated for the Case Status and Case disposition within the Case Life Cycle.
- Worked as QA as part of the Quality checking and auditing of cases to review the case analysis before they were moved to Consumer Outreach Team for further processing.
- Also verified the test scripts before manual execution if they cover all the aspects of rate and quote details according to State Medicaid and Medicare Policy coverage selection
- Updated the Analyst notes consistently in 1095 Issue Tracking Page of Share Point of Confidential according to case analysis in Workbook and customized the view of Share Point for ease access of Case tracking and Daily Report.
- Researched on HICS (Health Insurance Casework system) portal for additional correlated cases or additional related cases to get additional information like Marketplace Model and case resolution details from issuers (QHPP) and CMS (center for Medicare and Medicaid).
- Researched on EDBO (CMS Medicare Beneficiary entitlement record or Research file sent by Opera to Confidential ), which is a Macro-enabled heavy Excel file, with certain search criteria or query to extract the rows of valid records of consumers necessary for Case analysis or consumer dispute determination in the workbook.
- Ensure system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
- Updated the BUU templates accordingly (Batch Update Utility) to case types to correct the data elements in 1095-A form and exported the workbook to Outbound Excel directory located in shared drive (VPN) for Opera.
- Used FileZilla as a cross platform FTP application to transfer the encrypted files to the shared drive (remote server) of Confidential .
- Prepared Daily Status Report and took minutes of Meeting (MOM) during team meeting for any policy updates.
Environment: Rational Rose, Rational Requisite Pro, MS Word, Rational Clear Quest, MS Visio, MS Project, Java, HTML, Windows XP, Oracle
- Wrote Business Cases after conducting meetings with business users, risk team and finance team.
- Acted as IO Analyst and worked closely with IO Manager, BU Sponsor and BU Contact. Measured business opportunity, description of solution and scope. Measured and documented Labor and Material Detail, Skill Set, Budget Cost to Achieve (CTA) Summary, Inflow Summary and Economic Analysis.
- Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
- Was responsible for data mapping of HL7 messages into relational database.
- Develop, design and implement department plan to operationalize new FACETS integrated processing system, to include but not limited to workflow, management oversight and performance analysis.
- Facilitated Change Control Board and Governance Board (CCB) meetings and acted as a liaison between parties impacted by the change requests.
- Developed straightforward RDBMS queries, knowledge of HL7 and xml interface messaging.
- Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
- Mapped all as-is business processes using BPMN standards on MS Visio.
- Conducted JAD sessions and created functional and technical requirement specification for application development based on Solution Delivery Process.
- Created a test plan and a test suite to validate the data extraction, data transformation and data load and used SQL and Microsoft Excel.
- Developed estimates, project plans (Microsoft project), training material, BI reports using Microstrategy
- Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
- Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
- Used the BPMN to GAP Analysis to bridge the gap between business processes.
- Coordinated end to end testing efforts of the HIPAA Compliance and EDI Transactions.
- Ran queries monthly to verify tie-outs for the business prepared by the technical resource to provide support for applications solutions supported by the Reporting and Analytic Finance team with emphasis on the Corporate Finance Cognos Planning Models.
- Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, Websphere and Cognos.
- Performed Impact Analysis and Gap Analysis.
- Responsible for conducting gap analysis as is to be for ICD9 and ICD10. Prepared Data Flow Models for code sets validating in Facets and Claim Process Engine.
- Recommended changes for improvement after analyzing operational procedures and methods.
- Documented issue list and risk list pertaining to various projects.
- Creation of Gap Impact Analysis and Operational Analysis Document for Medicaid Subrogation
- Wrote use cases and verified that they match every single requirement of the application.
- Prototyped the application, provided screen shots for better visualizations.
Coordinated and collaborated the business, operations and the technical areas throughout the project life cycle.
- Create presentation style reports with chart and graphs which can be used to access any type of data source Presented reports to management and provided user training and acceptance tests.
- Performed manual testing and recorded results in Clear Quest and used SQL queries for enhancements.
- Performed the user acceptance testing.
- Conducted user interviews at both in-house and client locations, gathering and analyzing requirements using Requisite Pro and Requisite Web
- Organized Joint Application Development (JAD) sessions with ETL team while having walkthroughs for mapping documents.
- Proactively search for opportunities to increase UX efficiencies
- Extensively used Agile Methodology in the process of the project management based on SDLC.
- Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, Object Oriented Design (OOD) using UML
- Worked extensively in Data consolidation and harmonization
- Gathered and documented Business Requirements, created Functional specifications and translated them into Software Requirement Specifications.
- Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirements
- Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
- Identify Member, Provider, Coverage, Medicare, and Medicaid.
- Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
- Used Facets 4.51 to receive, store and send HIPAA-standard transactions (835, 837, 270, 271, 276, 277) and to administer HIPAA privacy rights.
- Developed test cases and test scripts and assisted Quality Assurance activities, with system integration testing and user acceptance testing (UAT), developing and maintaining quality procedures and ensuring that appropriate documentation is in place.
- Involved in claim adjudication process of FACETS application.
- Used Trizetto Product NetworX Pricer and the terms used in the Pricer.
- Interacted with Subject Matter Experts (SME), claimers, customers; Conducted detailed interviews with them, recorded the requirements, and reviewed the gathered requirement by both technical and business people.
- Responsible for identifying and documenting business rules and creating detailed Use Cases
- Developed ETL mappings, testing, correction and enhancement and resolved data integrity issues.
- Identified the source and target tables. Developed mapping document using MS excel.
- Design, development, implementation and roll-out of Microstrategy Business Intelligence applications.
- Determined the natural keys for the target tables.
- Created the conceptual, Logical and Physical Model for the data warehouse with emphasis on insurance (life and health), mutual funds and annuity using Erwin data modeling tool.
- Participated in the process of internal and external auditing activities and developed timelines for project delivery, and managed projects and resources to successful completion
- Mapped provider data from source to target Facets 4.71 data layout for the claims and benefit configuration.
- Responsible for executing User Interface Testing, System Testing, Data Quality Testing on the configuration design and prototypes in Facets 4.51.
- Participated in frequent Agile team meetings (Scrum planning, daily stand-ups, retrospectives) to provide UX input and guidance to an Agile product development process.
- Experience working with Health Care Client Server Product TRIZETTO FACETS
- Involved in data dictionary management, extraction, transformation and loading (ETL) of data from various sources. Participated in ETL requirements process during data transition from source systems to target systems
- Defined, developed specs for federal reporting specific to Medicare Advantage
- Involved in Data Analysis & Mapping to track all data elements used in the application from the user interface through different interfaces to the target databases in which they are stored.
- Developed tables, Views, Stored Procedures and Triggers using SQL Scripting
- Established Inner Join, Outer Join and created Indexes whenever necessary
- Facilitated internal review sessions with the BI and ETL team and external review sessions.
- Writing Complex SQL queries and optimizing SQL Queries.
- Documented Medicare claims processing.
- Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize FACETS features not provided by the legacy systems.
- Responsible to meet the information demands of our business users by delivering timely, accurate, meaningful and standardized data and reporting
- Participated in creating logical and physical data models, their enhancement. Based on the data models, worked with business architect, to create the software solution models.
- Helped in creating of Data-Mapping best practices document including visual processes and trained team members on Data Mapping process and tools.