- 8+ years of experience working as Business/Systems Analyst in Healthcare domain.
- Specific expertise in Business Analysis, GAP Analysis, Data Analysis, and creating business process documents.
- Detailed knowledge of the Software Development Life Cycle (SDLC) phases.
- In depth knowledge and hands on experience working with SDLC methodologies like Waterfall, RUP and Agile.
- Expertise in preparing Business Requirement Documents, Use Case Specifications and Functional Specifications.
- Hands on experience of UML diagrams such as Use Case Diagrams, Activity Diagrams and Sequence Diagrams.
- Experience in using Joint Requirement Planning (JRP) and Joint Application Deployment (JAD) sessions for gathering requirements and brainstorm ideas.
- Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
- Experience working in a FACETS environment and extensive knowledge about various modules of a FACETS system such as claims, membership
- An excellent knowledge of ICD - 9 and ICD-10 structures and formats.
- Well experienced with the complex tasks of ICD 9 to ICD 10 conversion and mapping.
- Strong understanding of EDI Claims, Member Enrollment, Eligibility, and HIPAA 5010 (X12) standards
- Knowledge of different modules within Healthcare Claims Adjudication Process (Membership process, billing process and enrollment & Claims process).
- Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
- Good understanding of various EDI X12 sets like … 850, 855, IDOC, XML, EDIFECS .
- Excellent experience various EDI files such as 837 Claims processing, 834 Benefit Enrollment, 820 Payments.
- Understanding of HIPAA EDI inbound and outbound transaction, and HIPAA 4010-5010 conversion analysis.
- Involved in EDI 834 (Enrollment and Maintenance), 837 (claim processing and clam adjudication including COB), 835 (Claim Payment and Remittance), and 820 (Payment Order and Remittance).
- Extensive experience in full HIPAA compliance lifecycle from GAP analysis and migration of HIPAA ANSI X12 4010 to ANSI X12 5010 and translation of ICD-9 codes into ICD-10 codes.
- Experience with HIPAA compliance in the Healthcare systems. Experience providing analysis for business processes running on EDI Transactions (Electronic Data Interchange) standard.
- Knowledge and experience working with FACETS claims processing, dental claims, & dental claim pricing.
- Ability to supervise and make sure testing is done with regards to requirements of the project.
- Experience in defect management using Quality Center.
- Experience in Claims Processing, claim encounters and Claims Scrubbing in HMO, PPO, Medicaid and Confidential .
- Hands on experience in writing SQL queries for data gathering.
- Excellent project management skills and hands on experience working with software like Microsoft Project.
- Experience creating testing documents such Test Plan, Test Cases, Test Strategy
- Excellent working knowledge of requirement management tools like Microsoft SharePoint.
- Excellent presentation and communication skills, can act as an excellent mediator between business and technical teams.
Sr. Systems Analyst
- Analyzed the impacts of HIPPA project on enrollment, Claims and Benefit.
- Worked on FACETS configuration, Customization, reporting, analysis and enhancement.
- Studied existing business application and processes, collected end user requirements and suggested the improvised business process model.
- Worked actively on developing the online pricing tool and web application.
- Implementing: pricing, capitation, membership, provider setup, provider contracts, benefit plan build, benefit grids for UAT Testing and Facets configuration
- Worked on Facets configuration payment methodology.
- Worked on FACETS Benefits Configuration to simplified benefit plan maintenance and renewal processes based on CSD provided by Benefits Analyst.
- Worked on healthcare standards such as HIPAA 4010, 5010, DICOMM, CPT, ICD-9 and SOAP.
- Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication).
- Worked in a team of six in an offshore/onsite model.
- Gathered requirements and created BRD for the Washington State Medicaid managed care incoming 834 enrollment file / data to FACETS for Accumulator Synchronization using ABI Subsystem to load in Facets Accumulator.
- Experience with Confidential, Medicaid and commercial insurances in HIPAA, ANSI, X12 formats including 270/271, 276,277, 278, 835, 837, 997.
- Analyzed Inbound and Outbound file layout in Facets delimited keyword format and successfully design and developed technical requirements.
- Worked as a part of FACETS configuration/implementation team.
- Analysis performed to ensure the resulting keyword file complements system configuration, ABI subsystem requirements with Ameri group internal Implementation team.
- Proposed FACETS claims adjudication procedures, standards and editing guidelines.
- Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler
- Conducted requirements analysis, developed SAP IDOC to/from X12 Gap documents for EDI documents for EDI Transactions.
- Resolution of EDI/IDOC portals for the inbound and outbound interfaces.
- Gathered, defined and documented highly complex business requirements for NPI crosswalk implementation.
- Participated in analyzing business requirements, Data Model Design, Data flow from various Sources to Target.
- As part of validation process for EDI 820, outlined the discrepancies in eligibility reconciliation process and updated the process after discussion with stakeholders.
- Created mapping for EDI Transactions, specially 820 and 834. Outlined the updated processes for Payment Reconciliation, Eligibility, and Premium Payment Transactions.
- Experienced in gathering requirements for HIPAA (Health Insurance Portability and Accountability Act) EDI Transactions (Electronic Data Interchange) 820, 834, 835, 837 (I, P and D), 270, 271, 276, 277, 278, 997 and 999 in various phases of implementation.
- Worked on functionalities such as Premium Payments, Enrollments and Claims.
- Responsible for documenting As-Is and To-Be systems.
- Involved in Project Planning, Coordination and QA methodology in the implementation of the Facets in the EDI Transactions of the claim module.
- Updated process flows for implementation of various modules for Facets including dental claim pricing, payment processing, & workflow management.
- Application integration with EDI-X12, EDI-820/834, Payment Reconciliation.
- Designed process flow for data archival, data purging, delta calculation during batch jobs to outline XML file triggers in Inbound & Outbound folders using transaction X12 EDI 820 and834.
- Interacted with Business Analysts and developers for the requirement clarification.
- Review and understand the claims process and complex requirements for the enhancement of the current system created under the Requirement Specification Documents after conducting interviews with End Users, JAD Sessions and analyzed their current systems.
Environment: IBM Mainframe, MS Office 2010, MS Visio, SAP, IDOC, Sybase HIPAA X12, MS Access (RTM & Test Cases), Lotus Notes, EDI 820/834/837.
Confidential, Hartford, CT
EDI Business Analyst
- Helped in defining Change Management Process for Release Management Team.
- Mapped process flow; assess as-is a process through user interviews, data collection and analysis, design 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.
- Involved in creating EDI Specifications, Test plans and for the 837 Institutional, 837 Professional, 835, 270/271, 276/277, EDI 5010 transactions with EDIFECS.
- Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Confidential ).
- 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.
- 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)
- Used EDIFECS Analyzer to compare the standards.
- Identified gaps in the business process.
- Developed and maintain information and documentation related to developing and modifying business processes and systems.
- Assisted process owners in process training and implementation.
- Streamlined the Restatement Financial Data Warehouse access review Process.
- Designed and developed project document templates based on SDLC methodology
- Involved in SAP Upgrade: Analyze the already existing legacy ERP system, EDI maps and prepare the gap document required for migration. Analyze the optimum number of maps necessary. Had meetings with SAP technical Architect to design the IDOC specifications necessary for the implementation.
- Created/ modified technical mapping specifications involving formats X12, IDOC, XML, flat file.
- Adopted 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.
- Facilitated Change Control Board and Governance Board meetings and acted as a liaison between parties impacted by the change requests.
Environment: SQL, MS Office Suite, Facets, UML, Visio, Clear Quest, HP QC, IDOC, SAP.
Confidential, Bethesda, MD
- Worked with business users to understand the Eligibility Reconciliation and Payment Reconciliation process.
- Created and maintained data mapping document(s) in reference to the HIPAA mandated X12 format EDI transactions 820, 834, and 835.
- Tested HIPAA regulations in Facets HIPAA privacy module.
- Worked on Involved in Confidential configuration, Customization, reporting, analysis and enhancement. Extensively worked on EDI transaction like 837,835,834, 820, 270, 271, 276, 277 and 278.
- Used gap analysis framework to identify AS-IS processes of claims transactions of HIPAA X 12 4010/4010 A standard and TO-BE processes (ICD-10-CM and ICD-10-PCS compliance requirements) of 5010 standard.
- Gathered business requirements, analyzed data sources, workflows by conducting interviews and meetings.
- Created business process models, flow diagrams, activity diagrams, use cases and wrote Business Requirement Documents (BRDs) and Functional Requirement Documents (FRDs) using tools and applications such as MS Word, MS Excel, and MS Visio.
- Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.
- Worked on FACETS claims processing, payment adjustments, claims inquiry, benefits,& dental claim pricing.
- Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.).
- Designed High level design, for New process, integrating with legacy and Facets
- Involved in configuration of Facets Subscriber/Member Application group.
- Analyzed the member/eligibility information on claim to that in Facets.
- Used Rational Clear Quest as a workflow tool for effective change management and for testing management.
- Performed responsibilities of integrating network in IVR systems as required
- Modified and redesigned the document for Plan Type Codes, Reason Codes, Relationship Codes, and Language Codes as part of Electronic Enrollment/Reconciliation process updates.
- Analyzed EDI 820 (Payments and Remittances) and 834 transaction (Enrollment and Maintenance) for the conversion of health insurance enrollment.
- Held JAD sessions to make sure all requirements were well understood by the team.
- Implemented the suggested changes and finalized the design to be presented to the developers.
- Designed Information Flows for Eligibility Reconciliation, Premium Payment Transactions, and Reconciliation of Enrollment Transactions EDI Processing to outline updated processes.
- Wrote SQL queries to gather data required for supporting the application development.
- Held meetings and constantly updated the BRD and FRD as per the changes requested by the stakeholders and approved by the Change Control Board (CCB).
- Followed the Waterfall methodology for all the modules throughout the entire SDLC.
- Actively conducted and participated in status report meetings and interacted with developers to discuss the technical issues.
- Modified the file format and layout for Electronic Enrollment & Reconciliation Payments.
- Actively participated throughout the User Acceptance Testing (UAT) process and helped coordinate the application deployment process.
- Worked independently with minimal supervision throughout the project.
Environment: Waterfall, MS Office, SQL Server, QTP, Quality Center, EDI 820/834/837/X12
Confidential, Virginia Beach, VA
- Interacted with the stakeholders and end users in order to define the purpose and scope of application and gather User Requirements.
- Developed Process/workflow analysis by understanding the process modeling.
- Validated business requirements by facilitating JAD sessions.
- Designed and documented Business Requirements (BRD) by using ASCI ASX X12 EDI guides, reviewed and interviewed business process owners and companion guides.
- Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
- HIP wanted to have data consistency and proper data mapping between the old and the new system. Developed the Business Crosswalks for 837(P, I, D), 835 and 276/277 according to HIPAA implementation rules.
- Analyzed and confirmed the source and target data in the database using Oracle SQL Developer.Updated Electronic Enrollment/Reconciliation Data Form.
- Created mapping for EDI transactions, specially 820 and 834. Outlined the updated processes for Payment Reconciliation, Eligibility, and Premium Payment Transactions.
- Tested EDI transactions 270/271, 837, 835, 834(X12) according to the test scenarios.
- Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment.
- Prepared business requirement documents and functional requirements using Rational Requisite Pro.
- Application integration with EDI-X12, EDI-820/834, Payment Reconciliation
- Facilitated meetings with users for requirement collection, design changes and feedbacks.
- Escalated issues and reported them as appropriate to Project management for support and guidance.
- Identified issues and worked with application and data team to resolve.
- Prepared Project Plan and Production deployment schedule using MS office tools (Word & Excel).
- Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage.
- Created and Designed SDLC Methodology for developing EDI applications used by hospitals to completely automate payments posting for Confidential, Medicaid and commercial payers electronic payments files.
- Followed UML based methods using MS Visio to develop use cases and activity diagrams; assisted developers in creating sequence diagrams and collaboration diagrams.
- Followed and implemented Agile methodology across multiple projects.
- Created and Maintained Test Matrix and Requirement Traceability Matrix.
- Worked with business partners and other groups to lead Quality strategies for projects and platforms
- Facilitated requirement review & update sessions with stakeholders to ensure all stakeholders are on boarded and approve the enhancements.
- Worked with UAT Testers to get feedback during UAT Testing and updated the requirement log.
- Created technical documentation, Reviews, analyzes, and evaluated business systems for end user needs, including Companion Guides, business process reengineering, including GAP analysis and documenting requirements, documenting processes, and workflows.
- Created Requirement Matrix, Process Flows, and Use Case Documents to support the implementation of Facets Billing and Claims Processing modules.
- Prepared user instructions and use cases to conduct User acceptance testing (UAT).
- Facilitated the requirement changes and fixes along with the release management team.
Environment: Windows XP, MS Visio, SQL Server, MS Access, MS Project, HP QC, Doors, X12, FACETS,EDI 820/834/837.