SUMMARY:

• Extensive experience working as Business Analyst/Quality Analyst for past 7 years in healthcare and IT domain.
• Worked extensively in different methodologies like RUP (Rational Unified Process), RAD (Rapid Application Development) and Agile.
• Experience in writing complex queries using SQL.
• Knowledge of Business Analyst book of Knowledge BABOK
• Trace and inform business requirement changes through the lifecycle of the project using Rational Requisite Pro and Rational Clear Quest while maintaining customer needs and maintain a Requirements Traceability Matrix (RTM) to keep the stakeholders informed of the progress of the project.
• Experience in developing Software Test Plans, Test Case Design, Test Scripts, Integration Testing, System, Functional, Regression Testing, GUI, and database testing.
• Over 7 years of all - encompassing experience as a UI Business System Analyst in all phases of System Development Life Cycle (SDLC).
• Extensive experience with SAFE Agile
• Excellent Experience in Defects Tracking in the Application.
• Experience on ServiceNow
• Documented the Business Requirements Document (BRD), generated the UAT Plan, maintained the Traceability Matrix and assisted in Post Implementation activities.
• Good understanding of Healthcare Industry claims management process, Medicaid and Medicare Services, Health care Reforms and Insurance sector.
• Good Knowledge of EMR/EHR, HIX (Health Information Exchange), Health Care Reform
• Strong experience in the creation of Test Plan and Test Cases from the Requirements document.
• Worked extensively in Agile environment creating user stories, sprint lifecycles documents, and essential business use cases.
• Extensive experience in capturing requirements for large scaled projects using Joint Application Development (JAD), requirements workshops, SME surveys, process analysis etc.
• Experience working with on Data Mapping and Data Extracting Strategies for data migration.
• Experience in using EDI, SQL, FACETS, Gentran, MS Visio, Rational Rose, Requisite Pro, UML
• Expert in designing User Interfaces and set up business logic to create high fidelity simulations by using IRise Studio and other tools
• Expertise in developing and implementing Six Sigma processes that ensure optimal production efficiency that meets critical timelines.
• Efficiency in using technology that includes SAP, MS Project, Oracle, MS SQL, Quantum Control ERP, and Value Stream Mapping.
• Strong ability to utilize critical thinking and dynamic problem-solving skills to design solutions that improve business processes and develop standardized process instructions for enterprise-wide implementation.
• Effective and Strong communication skills while communicating with internal and external customers and while negotiating with various business units and suppliers.
• Designed and installed testing platforms for development and user acceptance.
• Analyzed and synthesized results from JAD and other requirements processes and transformed those into Business Requirement Document (BRD), Functional Requirement Specifications Document (FRD) and Use Case Narratives.
• Extensive knowledge using Unified Modeling Language (UML) diagrams (use case, activity, sequence) using Rational Rose and MS Visio.
• Worked on all major Healthcare initiatives like HIPAA migration from 4010 to 5010, ICD 9 to 10 migration, Affordable Care Act (ACA or Obamacare) and Health Care Reform initiation.
• Extensive knowledge in Health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI), HL7 and ICD-9 to ICD-10 coding.
• In depth analysis and working experience in data modelling, data profiling, data warehousing, Metadata Management Services, and other data concepts.
• Worked with HIPAA 5010 and Electronic Data Interchange (EDI) with Transaction code sets such as 837 (medical claims), 835 (medical claim payments), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), 277 (claim status response), 820 (enrollment), and 834 (premium payments).
• Extensive experience in Electronic Health Records (EHR) and Patient Protection and Affordable Care Act (PPACA).
• Extensive knowledge on the various types of health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO (Preferred provider organization), HMO (Health maintenance organization), and POS (Point of Service).
• In depth Knowledge of MMIS (Medicaid Management Information System), MITA (Medicaid Information Technology Architecture, HIX (Health Insurance Exchange), EMR (Electronic Medical Record), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA), Emergency Medical Treatment and Active Labor Act (EMTALA)
• Experience in conducting GAP analysis, SWOT analysis and Root Cause Analysis.
• A solid base in gathering and documenting user and business requirement.
• Knowledge of HL7 message structures, data definitions, and usage.
• Worked as a liaison between developers and management and between end users and stakeholders, was instrumental in resolving conflicts between the various teams.
• Experience working on AS-IS and TO-BE processes.
• Knowledge and expertise in working with Claims, Provider Relations, Enrollment, Benefits Administration, and Vendor Relations Business Areas
• Vendor Management - Worked as a facilitator for Testing Efforts and New Requirements between the Healthcare Company and its various Vendors
• Defining test cases, creating test scripts, analyzing bug, interacting with testing & developing teams in fixing errors.
• Analyzed business requirements from black box testing perspective, business process and system design
• Experience working with on-shore, offshore, on-site, and off-site individuals, and teams.
• Extensive Competency in writing, reviewing, and executing Validation Protocols as per federal regulations.
• Excellent Communication, Interpersonal, Analytical skills, and strong ability to work with minimal supervision as well as a part of team

TECHNICAL SKILLS:

Methodologies: Waterfall, SDLC, Agile(SCRUM), UML, JAD, RUPRational Tools: Rational Rose, Rational ClearQuest, Rational Clear Case, Rational Requisite Pro and Rational S0DA

MS Office Tools: MS Visio, MS Outlook, MS Word, MS Excel, MS Excess, MS PowerPoint and SharePoint

Databases: SQL Server, Oracle, DB2 and MS Access

Operating Systems: Windows, MAC, OSX, LINUX

Testing Tools: HP ALM, SOAPUI, JIRA, Clear Quest

PROFESSIONAL EXPERIENCE:

Confidential, Norfolk, VA

Business System Analyst

Responsibilities:

• Worked in the Scaled Agile Framework (SAFE) environment
• Extensive experience working with JIRA and Confluence to track bugs and coordinate on a team level
• Gathered business requirements from SME’s and Business users and efficiently coordinated the same with the development team
• Successfully conducted Product Increment planning as a part of SAFE and broken down the requirements for the upcoming sprints
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
• Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
• Responsibility included modifications to a customer’s mainframe system to support new product features or regulatory requirements and, in some cases, involved a system upgrade.
• Converted Business Requirements to the Functional Specification and Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Developed global reports using client based Business Objects and ServiceNow data sources to assist global and regional managers on how to better serve the client.
• Use Cases and other Process Flow Models were designed using Visio and Rational Rose.
• Helped in developing QA Test plans for Systems integration and System Testing. Performed Black Box Testing. Performed GUI testing and user acceptance testing (UAT).
• Participated in the bug review meetings, updated requirement document as per business user feedback and changes in the functionality of the application.
• Organized meetings to discuss outstanding issues with QA team and developers.
• Extensively demonstrated Proficiency in creating charts and mockups on Tableu and conduct demos with the stakeholders of different departments to get sign-off on functional requirements.
• Involved in User Acceptance Testing
• Coordinated with the development team in documenting End User Manual.
• Identifying and understanding the business-critical areas from the user perspective.
• Managed change of the requirements and associated requirements to other requirements for traceability using Enterprise Architect.
• Involved in drawing data flow diagrams and process flow diagrams using MS Visio for the Claim Adjudication module.
• Involved in generating Test Plans and Test Specifications as per Business requirements
• Developed business architecture using requirements such as scope, processes, alternatives, and risks.
• Led Agile business requirement gathering sessions and design sessions with users in workshop setting
• Conducted different levels of testing including functional, user acceptance, integration and performance to verify the client's needs are met.
• Worked closely with stakeholders to understand their Business Processes, including current state and the desired "to-be" state and documentation of requirements and conceptual design from which application and solutions are developed.
• Communicated with client's business requirements by constructing easy-to-understand data and process models.
• Provided input into developing and modifying systems to meet client needs and develop business Analyze client's business requirements and processes through document analysis, interviews, workshops, and workflow analysis.
• Managed and prioritize a backlog of user stories
• Liaise between business and technical personnel to ensure a mutual understanding of processes and applications.

Environment: Window, Linux, Mainframe, Solaris IBM Web sphere, Oracle, SQL Server, DB2, MS-Project

Confidential, Oakland, CA

Business System Analyst/ EDI Analyst

Responsibilities:

• Involvement in gathering requirement to structure BRD
• Gathered technical and functional client requirements and managed those requirements through clear and precise documentation.
• Acted as client liaison for engagements with Off-Shore development team
• Provided leadership with respect to integration issues including process mapping, business process re-engineering, SAP integrations, and change management.
• Communicated with the trading partners and explain them the testing process conducted by Kaiser for the upcoming EDI enhancements, understand their requirements and assign testing slots to them according to their availability and requirements.
• Gathered information on inherent systems (clinical, administrative, laboratory, pharmacy) to have understanding of the business processes and EDI
• Collected the EDI files from testers and send it to the suppliers after a high-level validation of the 850 and 844 EDI files.
• Worked in another team where I was involved in EDI detailed testing for the customers of Kaiser
• Was responsible for EDI map analysis, development, testing and implementation.
• Analyzed current EDI maps
• Implemented changes to current EDI maps.
• Functional, smoke and regression testing on all environments.
• Performed Data Mapping, Business, and Data impact assessment on EDI transactions.
• Extensive experience in creating Context Diagram, Business Process Flows, Activity Diagram, Use Cases and UML Diagrams using various tools like MS Visio, Enterprise Architect and IRise
• Responsible for administrative tasks on project, to include project team member time reporting
• Conducted JAD sessions for the new MMIS with SMEs to obtain domain level information, interviewing and asking detailed questions and carefully recording the requirements in a format that can be reviewed and understood by both business and technical teams
• Responsible for developing applications for physicians' electronic billing and scheduling, and electronic medical records (EMR).
• Successfully handled the testing of health care products like Epic Systems and EHR (Electronic Health Record).
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Supporting client’s HEDIS Processes and Reporting needs, and helping them to reach new levels of performance.
• Worked on requirements and completely developed the new process for HEDIS data processing.
• After Executive confirmation did Gap analysis to assess needs that could not be met by core EHR.
• Worked closely following the CMS goals for Five-star rating system.
• Worked on Electronic health record system as a CRM web-based application.
• Developed extensive experience in eligibility and benefits calculation for state, federal and local services such as Medicare and Medicaid.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Worked on Claims Processing per Medicaid Management Information Systems (MMIS) 42 CFR 433.
• Identify Member, Provider, Coverage, Medicare, and Medicaid
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access.
• Reviewed Stored Procedures for reports and wrote test queries against the source system (SQL Server) to match the results with the actual report against the Data mart (Oracle).
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Established a RUP (Rational Unified Process) centric business analysis methodology.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and ER Diagrams in MS Project.
• Automated confidence tests that run on new builds on regular basis.
• Managing overall testing process and project to production change management life-cycle.
• Performed SWOT Analysis and ROI Analysis to identify various internal and external factors.
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process, and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.

Environment: Window, Linux, Mainframe, Solaris IBM Web sphere, Oracle, SQL Server, DB2, MS-Project

Confidential, Buffalo, NY

BUSINESS SYSTEM ANALYST/ PROJECT COORDINATOR

Responsibilities:

• Responsible for gaining a good understanding of User needs and accurately representing them in a well-documented software functional specifications document.
• Gathered Business Requirements, interacted with the Users, Designers and Developers, Project Manager, and QA Team to get a better understanding of the Business Processes.
• Interacted with the “End-Users” by interviewing them, by preparing appropriate questionnaire to better understand end-user needs and the business process.
• Followed Agile (Scrum) SDLC methodology software development
• Followed a structured approach to organize requirements into logical groupings such as requirements for Customer, Client, Group, Member, and Reporting that critical requirements are not missed.
• Functioned as Project Manager and handled planning, creation of project schedule, team management, creation of process documents, and initiation of go-live activities.
• Facilitated communications with all stakeholders and senior management.
• Created functional flow charts and standard process instruction that meet business requirements for each project.
• Consistently met performance goals
• Utilized trend analysis to design and implement process improvements that included coordination with Purchasing and Logistics to improve management of parts overhaul and parts procurement for each project.
• Involved in creating Business Process Documentation. Identified Use Cases from the requirements. Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams using MS-Visio.
• For Project management purpose worked on Microsoft Project, used Microsoft Share Point for maintaining the updated Documentation.
• Microsoft Office (Outlook, Word, Excel, Visio, Access) at various phases of development for documenting the requirements.
• Analyzed and optimized the process, Prepared Business Requirement Document and managed requirements using Rational Requisite pro.
• Facilitated JAD sessions with business and technical units to fine tune prioritize and detail requirements and use cases.
• Analyzed business requirements for the Quality Measurement Rules specifically HEDIS and CMS STAR measures for the Medicaid population.
• Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
• Worked on Facets Claims Processing for data validation and claims validation. Extensively worked on Claims Inquiry and Dental Claims Processing.
• Frequent use for Gentran for data conversion.
• Conducted Claims and HIPAA Compliance Training to run the test cases. Also worked with NPI
• Experienced in X12 transactions 835/837/834/820/271 of medical claims/underwriting for support and point of reference for the vendor in business issues.
• Authored Data flow diagram, sequence diagrams and business process models that describe how the EDI Health Care Claim Transaction set (837) is used to submit health care billing information and encounter.
• Involved in identifying and studying the ACES and Facets system data and field by field analysis of Facets system for the attribute mapping purpose
• Led major team projects in regard to the National Committee for Quality Assurance (NCQA) HEDIS measures
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML.
• Managed RTM (Requirement Traceability Matrix) to track the project flow.
• Prepared BRD and Derived Functional Requirement Specifications (FRS) based on User Requirement specifications and delivered to the project team. Understand and articulate business requirements from user interviews and then convert requirements in to technical specifications

Environment: MS Office, MS Visio, UML, Rational Clear Quest, Adobe Acrobat, PL-SQL, Oracle, SDLC, SharePoint

Confidential, Seattle, WA

BUSINESS SYSTEM ANALYST/ QUALITY ANALYST

Responsibilities:

• Gathered Business Requirements from all the stakeholders and interacting with the providers, managers, developers to develop the business Processes.
• Conducted Risk Analysis and Impact analysis whenever there is any change in the business requirement and proposed solutions while continually updating the business requirement document.
• Functioned as an ERP System Analyst and provided functional training for end users in each department and worked with IT to facilitate systems integration between ERP and business needs.
• Participated in the SAP data migration of inventory into Quantum Control and created effective security roles.
• Participated in enterprise-wide training required by the transition from SAP to Quantum Control in Procurement, Logistics, and Operations.
• Conducted JAD sessions and ultimately reducing the time spent in moving all the information from stakeholders and other team members.
• Provided education for HEDIS measures, appropriate medical record documentation and appropriate coding.
• Assisted in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS.
• Created and updated data mapping document(s) with reference to the source for 270/271 (Eligibility & Benefit Inquiry & Response), 276/277 (Claim Status Inquiry & Response) and 837 (Health Care Claim).
• Assisted in the meetings with the technical team as well as the clients regularly to assess the current process and how it could be changed in making a better proposed process.
• Performed six-sigma process during the project to eliminate any defects in the process.
• Conducted the gap analysis and analyze various gaps and develop actions to fill those gaps.
• Developed spike requirements solution for all the current problems and UI prototypes for capturing the requirements.
• Helped in developing test cases such as test plans and test scenarios.
• Utilized Rational Unified Process (RUP) and build different phases of software developmental cycle.
• Actively involved in designing EDI transactions using the new HIPAA 5010 version and ICD -10 codes and analyzing IPAA compliance and EDI transaction.
• Recommended actions against the action plans during the ongoing progress of the project to the project manager.
• Gathered knowledge of the software system and the programs.
• Identified of changes in the existing North Dakota Electronic Disease surveillance system to adopt ELR implementation through GAP analysis.
• Created architectural styles such as application architecture, enterprise architecture, and service-oriented architecture with the help of Service - Oriented modelling (SOA).
• Created project management plans to manage timely delivery using MS project.
• Performed Requirement Tractability Matrix (RTM) to track and maintain stakeholders requested requirements and changes.
• Instrumental in capturing the requirements from the clients and publishing them into a requirements document.

Environment: MS Project, Requirement Traceability Matrix (RTM), Rational Rose Test, JAD, RUP, MS Visio, Windows OS, MS Office, SharePoint, Server, Quality Center, ETL, FACETS, SQL Server.

Confidential, Milwaukee, WI

BUSINESS ANALYST

Responsibilities:

• Served as a BUSINESS ANALYST on multiple initiatives involving maintenance and system changes for HIPAA implementation. Gathered and documented existing client processes and data using Microsoft Excel to perform gap analysis between systems and to access client readiness.
• Revised Quality of Care Concern process; developed submission form, database, and reports
• Developed Data Flow, Work Flow, Process Flow, and Entity Relationship Diagrams in MS Visio, and analyzed them to create “AS IS” and “TO BE” scenarios.
• Verified the functional aspect as per the Business Process and validated the interfaces with the other systems and data conversion from the existing system.
• Gathered requirements for the design and implementation of CMS STARS / HEDIS reporting tool.
• Configured and optimized COGNOS BI environment, which includes relational, and OLAP layers, and data migration components; working in collaboration with the data warehouse environment and team.
• Validated the following: EDI 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)
• Experience with membership and billing variable mapping, integration of variable mapping to downstream applications for 820 files processing.
• In depth knowledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors.
• Develop scripts and test cases for Integration Testing, Regression Testing and Stress Testing.
• Developed and managed SharePoint site to host collections for project analytics, client databases, requirements and reports.
• Analyzed business requirements for the Quality Measurement Rules specifically HEDIS and CMS STAR measures for the Medicaid population.
• Acted as a liaison between Business Area Subject Matter Experts (SMEs) & development team throughout all phases of SDLC; starting from Inception to Transition phase of the life-cycle.
• Updated data processes, data reporting, data collection tools and other processes such as problem lists, writing orders, referrals according to ICD-10 code set
• Actively involved in designing EDI transactions using the new HIPAA 5010 version and ICD -10 codes and analyzing HIPAA compliance and EDI transaction.
• Analyzed different systems (FACETS, CODS, RAPS, NEXTGEN) for billing integration.
• Ensured that ICD-9-CM procedure codes used for services and CPT codes were not outdated.
• Contributed in ICD-10 Awareness Training Management Plan, created evaluation tool, and survey questions
• Reviewed state documents (policies, manuals, business processes, systems documents, banners, bulletins) from various divisions. Analyzed and performed quality assurance to determine areas impacted by ICD-9 related data
• Assisting in Enrollment (EDI 834), Billing Entity configuration, Claims (EDI 837) and BDS (Business Distribution System) business process flow.
• Gathered user and business requirements through open-ended discussions, brainstorming and prototyping to achieve the following goals.
• Involved in configuration of FACETS Subscriber/Member application
• Worked on FACETS Data tables and created audit reports using queries. Manually loaded data in FACETS and have good knowledge on FACETS business rules.
• Prototyped the automation and enhancement of the manual processes in member enrollment, terminations and reconciliation

Environment: MS Office, MS Visio, UML, Rational Clear Quest, Adobe Acrobat, PL-SQL, Oracle, SDLC, SharePoint