PROFESSIONAL SUMMARY

• Around 7 years of Business Analysis experience with in-depth knowledge of business processes in Health Care and Banking Industries.
• Proficient in Requirement Management, including gathering, analyzing, detailing and tracking requirements.
• Experienced in interacting with business users and executives to identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD), Use Case Diagrams, Activity Diagrams and Sequence Diagrams using UML modeling.
• Expertise in facilitating and conducting Joint Application Development (JAD), Rapid Application Development (RAD) and Joint Requirement Planning (JRP) sessions, interviews, workshops and requirement elicitation sessions with end-users, clients, stakeholders and development team.
• Several years of experience and advance knowledge of the Systems Development Life Cycle (SDLC), Waterfall, Agile, Spiral, Extreme Programming (XP), and Rational Unified Process (RUP).
• Strong Knowledge with Iterative approach for Software Development as per Rational Unified Process (RUP). Involved in inception, elaboration, construction & transition phases using rational tools like Requisite Pro, Clear Case, and Clear Quest during various phases of RUP.
• Skillful in performing GAP analysis, SWOT analysis, Cost benefit analysis, Risk analysis and User acceptance Testing (UAT).
• Extensive knowledge of Healthcare Insurance including Medicaid (Part A, B, C, D), Medicare, Procedural and Diagnostic codes, Claims Process and Medical Management Information Systems (MMIS)
• Profound experience in with HIPAA 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).
• Experience in Conversion of HIPAA X12 4010 codes to X12 5010 code, ICD 9 codes to ICD 10 codes and HL7.
• Knowledge of Patient Protection and Affordable Care Act(PPACA), Electronic medical records (EMRs) and Electronic health records (EHRs)
• Experienced in writing Test Plans and executing Test Cases.
• Strong Subject Matter expertise in Credit Card Industry, Retail/ Commercial/Investment
• Outstanding organizational skills including ability to multi-task, prioritize and manage increasingly complex issues with integrative thinking, communicating skills and recognized for being a valued team player.

AREAS OF EXPERTISE

Operating Systems:

Windows, UNIX, LINUX and Mac

Languages:

SQL, C, C++, Java, XML, C#, VB, ASP, .Net, Assembly, VHDL

Databases:

Oracle, MS SQL server, MS Access, IBM DB2

Tools:

MS Office, MS Project, MS Visio, Front Office, Rational Rose, SoDA, Software Modeler, Team Test, Doors, PROLOG, Clearcase, Clear Quest, , WebSphere, Business Modeler, HP Quality Centre, Ultra Edit, TOAD

Industry Standards:

HIPAA, SOX, ISO, Six Sigma, CMM, HL7

PROFESSIONAL PROFILE

Confidential,Woodland Hills, CA Feb 2010 – Present
Sr. Business Analyst
Confidential, is the nation\'s largest health benefits company in terms of medical membership. During this period WellPoint completes the transition of its commercial UniCare membership in Illinois and Texas to Health Care Service Corporation (HCSC), as well as migration to then announced Health Insurance Portability and Accountability Act (HIPAA) 5010 rules by Department of Health and Human Services (DHHS). The implementation of HIPAA and ICD-10 code set standards intended to improve patient care quality, enhance claim processing, improve data reporting and promote increased interoperability across industry stakeholders.
The transition from UniCare to HCSC required an extensive cost evaluation and process improvement analysis. A competitive cost study was carried out for the states of Illinois and Texas, based on their subsidiary. It involved benchmark study of the business process with competitive products by parallel analysis of various business cases and evaluation of the feasible strategic plans for process improvement under health reform legislation.
The assessment process for HIPAA 5010 migration consisted of a business-impact assessment, compilation of results, gap analysis, and developing business case. The business-impact assessment (BIA) as a part of Business Continuity Plan (BCP) provides BIA reports to identify costs linked to failures. The results were compared with the related HIPAA standards to determine the current level of compliance and used to develop an action plan for presenting to the project steering committee.

• Roles and Responsibilities:
• Facilitated and documented Requirements gathering sessions among the stake-holders, technical teams and business units.
• Gathered and analyzed the system requirements along with team leads and user-representatives through Joint Application Development (JAD) sessions.
• Conducted gap analysis between as-is and to-be process flows, using simple questionnaire sessions with Subject Matter Experts (SMEs).
• Facilitated feasibility analysis sessions between the business units and technical experts.
• Carried out extensive quantifiable analysis over the Business Requirement Specifications with respect to legislation reform implementations on the current system.
• Extensively participated in planning RUP iteration deliverable and documented the artifacts throughout the various phases of migration from HIPAA 4010 to 5010.
• Documented the functional and non-functional specifications, and developed Business Requirement Document in support of System Requirement Specification document, and Summary Reports.
• Carried out a parallel process for Cost-Benefit evaluation for the current UniCare system and proposed migration.
• Documented and facilitated a series of interviews with business experts and technical third party experts to validate the non-preferable transition of the process flow.
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010 using EDIFECS for achieving compliance.
• Validated the compliance of HIPAA 5010 standards with the requirements gathered, and conducted process design sessions with technical teams.
• To ensure continued business processing, generated a parallel documentation for the HIPAA 4010 process already running.
• Responsible forgap analysisin changing old MMIS and Involved in testing new MMIS.
• Designed and implemented Business Continuity Plan and analyzed critically the outcomes with technical leads to avoid any catastrophic risks.
• Enhanced the transition process flow to facilitate a smooth migration, hence closing cross-walk gaps in the two versions of standards.
• Extensively analyzed the transition related requirements and ensured high level compliance with the HIPAA 5010 and ICD -10 codes.
• Recommended corrective actions, if necessary, along with the progress against Development/Action Plan routinely to the Project Lead.
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Knowledge of the complete Electronic Data Interchange (EDI) format used in electronic documentation, which was part of the knowledge transfer program to the vendors as per the requirements.
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped.
• Used SQL for data mapping and querying.
• Developed test cases in UAT to ensure high degree compliance with HIPAA 5010 standards and validating over-all business process after deployment.

Environment: MS Office, Quality Center, SQL Server, MS Project, Server, MS Visio, Unix, J2EE, Java, XML, Mainframes and Rational, Windows XP.

Confidential,Scottsdale, AZ March 2009 – Jan 2010
Business Analyst

Confidential,provides managed behavioral healthcare, radiology benefits management, specialty pharmaceutical management, and Medicaid administration products and services in the United States. The company provides services to health plans, insurance companies, employers, labor unions, and various governmental agencies.

Project scope included ICD 10 Care Management Impact Analysis:Care Management utilizes multiple software systems to support the intake and processing of authorization requests, the exchange of data between the payer and vendors contracted to perform services on our behalf, manageCase and Disease programs, provide robust reporting and decision support, and generally automate and facilitate their business processes. The authorization requests consume ICD 9 codes that need to be replaced by ICD 10 codes to meet the mandate date.

• Roles and Responsibilities:
• Coordinated with the stakeholders, Application Vendor, Clearinghouses and project key personnel to gather functional and non-functional requirements during JAD sessions.
• Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, Medical policy waves.
• Performed the Gap analysis of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
• Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD 10 such as EDI Claims Intake, FACETS- Claims Adjudication, Medical Management- Utilization Management, Case management and Provider Reimbursement- Provider Payment.
• Worked on Financial Analysis of DRG shifts from ICD 9 to ICD 10 to avoid any over or under payments to the providers.
• Organized impacted systems into high, medium and low impact to help business analyze the level of effort for remediation activities and ease resource allocation work.
• Prepared use cases and data flow diagrams to analyze the impact of ICD 10 diagnosis codes embedded in different systems and applications.
• Prepared and maintained Requirements Traceability Matrix (RTM) to track the progress of business requirements.
• Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements.
• Designed and developed Business Rules document about the Claim Component and HIPAA.
• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed Business Requirements Document (BRD) including all functional and non-functional requirements.
• Specifications, Documentation and Construction of systems heavily relied on UML.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837 (Health care claim), 270/271 (inquire/response health care benefits), 276/277 (Claim-status), 835 (Payment/remittance advice), 834 (Enrollment and Benefit Maintenance) EDI transactions.
• Designed robust 5010 testing and 4010 regression SIT and UAT Testing Scripts for the 5010 Project.
• Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis expected results for 5010 compliance.
• Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
• Took action in the process flow to prevent rejected claims from falling into “limbo”.
  Mitigated claim denial increase through a complete analysis of the application “Claims Scrubber” to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.
• Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.
• Tracked all required resolutions required that were identified as needed from Vendors or Payers based on testing results.

Environment: MS Project, MS Access, MS Excel, MS Word, MS Power Point, Rational Requisite Pro, Clear Case, Clear Quest.
Confidential,West Palm Beach, FL Jan 2008 – Feb 2009
Business Analyst

Confidential,through its subsidiary, Metcare of Florida, Inc., operates provider services network (PSN) in the United States. Its PSN provides and arranges for medical care primarily to Medicare advantage beneficiaries who participate in a Medicare advantage program.
Coordination of Benefits (COB) is a federal Health Care Financing Administration (HCFA) Program. Medicare Coordination of Benefits is the process for ensuring that payment of Medicare beneficiaries\' claims is properly shared among insurers when the beneficiary is covered by private insurance in addition to Medicare. By coordinating benefits, the COBC assists Medicare in paying claims more accurately the first time, which saves costly follow up and mistaken payments.

• Roles and Responsibilities:
• Gathered requirements by conducting meetings and brainstorming sessions with end users and Subject Matter Experts (SMEs) and documented them using Requisite Pro.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Responsible for processing Medicare claims and COB claims.
• Responsible for checking Medicare eligibility and verifying claim payment.
• Experienced in Medical Claims Process Documentation, Analysis and Implementations in835/837(Health Care Claim Payment/ Submission),270 (inquire/response health care benefits),276/277 (Claims- status) processes or Medical Claims Industry from the Provider/Payer side.
• Designed and developed a universal HL7 file transfer utility using Epic BRIDGES.
• Gathered requirement for HIPAA 4010-HIPAA 5010 and ICD9-10 conversion.
• Analyze HIPAA 4010 -HIPAA 5010 changes.
• Met with various HMO, PPO, Medicaid/Medicare Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues.
• Developed and maintained all operational and technical flows using Visio and Power point.
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models.
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams, and Collaboration Diagrams thus defining the Data Process Model and Business Process Model.
• Written multiple Use Cases and test cases for multiple transactions including 837, 835, 270, 271, 276, 277.
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Aided in workflow analysis and process design.
• Analyze business requirements from Black Box testing perspective, business process and system architecture/design.
• Maintained Requirement Traceability Matrix (RTM).
• Performed Regression Testing and created test scenarios for User Acceptance Testing (UAT).
• Maintained documents for change request and implemented procedures for testing changes.
• Defined program and project goals, objectives, products, services, constraints, assumptions, risks and facilitated processes by working with the project team, sponsor, and stakeholders to baseline the scope of the work and enable development of the plan.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Developed business process models in RUP to document existing and future business processes.
• Performed SWOT and Gap analysis for the new functionality requirements by identifying existing technologies, documenting the enhancements to meet the end state requirements.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Involved in generation and execution of SQL queries.

Environment: Rational Unified Process (RUP), UML, Rational Test Manager, Rational Clear Quest, Windows, MS Office, HTML, Windows 2003

Confidential,Springfield, MA Feb 2007 - Dec 2007
Business Analyst
Confidential,offers range of health care coverage options to individuals and through employer groups. The project involved building a Enterprise SOA (service-oriented architecture) based system that was to be developed on the Microsoft .NET Platform. The new Claims Processing MMIS (Medicaid Management Information System) will replace the old legacy system thereby automating all the business areas with minimum human intervention. As a Business Analyst, I was involved with drafting the migration plan for the Claims Processing data which needed to be migrated from the Mainframe to the SQL Server environment.

• Roles and Responsibilities:
• Conducted requirement gathering sessions with the Information Technology team.
• Attended JAD sessions for Requirement Validation to gather requirements for the new MMIS.
• Developed Use Cases, Activity diagrams and Sequence diagrams from the requirements based on the UML methodologies using MS-Visio.
• Involved in the design and development of User Interfaces (UI) using HTML, JavaScript and JSP.
• Held periodical meetings with the Development team to gather information on the progress and resolve project issues.
• Used Microsoft SharePoint as the version tracking tool for managing the requirements documentation.
• Performed an analysis of requirements so that they are in compliance with
• Requirement Traceability Matrix (RTM) was maintained through RequisitePro to keep the timelines and milestones in check.
• Helped the testing team in carrying out manual testing and also assisted in writing test cases and a Test Plan.
• Tested the final application for Usability testing to verify whether all the User Requirements were catered to by the application.
• Bugs that would enhance the usability of the application were logged using Rational ClearQuest.
• Interacting with the developers on resolving the reported bugs and various technical issues.
• Tested the features and functions based on priority using Rational Quality Manager.
• Involved in preparing a simple and detailed User manual for the application, for an intended novice user.

Environment: Rational RequisitePro, Rational Rose, UML, MS-Project, MS Visio, Java, MS Office, Windows XP, Microsoft SharePoint, RQ

Confidential,Bristol, CT Jan2006 – Feb2007
Business Analyst
Confidential,provides commercial, retail banking services as well as different credit cards to customers and businesses. The client wanted a more accessible and comprehensive application that has viewing ability, which would enable customer to easily access various features. As well as the application was supposed to be connected with the customer service to update data, payment information, transactions and so on. The front end used was JAVA, HTML whereas the backend used was Oracle.

• Roles and Responsibilities:
• Stakeholder interviews, Requirements review, preliminary system design, and joint application design workshops, develop the Test Evaluation Master Plan, and Error and Corrective Policy and Procedure.
• Created a test schedule to conform to the confines of the Project Schedule and also deliver value to client.
• Shopped and procured automated testing tools facilitating Program Policy and Standards and compliance; support repeatable testing procedures.
• Developed project delivery schedule, managed projects and identified resources to successful completion.
• Set up HR vendor system, Benefits, Benefits Open enrollment, Compensation and Payroll.
• Managed Project Management staff, Quality Assurance and Technical Writing staff.
• Managed open enrollment technical projects for 20,000.
• Acquired comprehensive knowledge of Banking activities and operating processes.
• Collected and documented business processes as well as business rules.
• Participated in the identification, understanding, and documentation of business requirements, including the applications capable of supporting those requirements.
• Translated the business needs into system requirements, communicating with the business on a non-technical level, and with the System Analyst on a more technical level.
• Collaborated with development architect and the business to develop both high-level and detailed application architecture to meet the business needs.
• Documented and delivered Functional Specification Document to the project team.
• Performed GAP Analysis and conducted User Acceptance Testing (UAT).
• Developed test scenarios and implemented test plan. Providing key input in working with users in defining project and system requirements.
• Conducted project related presentations.

Environment: Rational Rose, MS Excel, MS PowerPoint, Test Director, Rational Requisite Pro, RUP, UML, Rational ClearCase.