- Have extensive experience as a Business Analyst in Healthcare domain.
- Experience Software Development Life Cycle (SDLC) methodologies like Waterfall, Agile - SCRUM
- Good knowledge of Health Insurance Plans managed care concepts (Medicaid and Medicare) and Revenue cycle experience within life and disability in health plans.
- Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans).
- In-depth knowledge of Healthcare organization operations including outsourced operations, Health Insurance, HIPAA, and Medicaid/MMIS, including MITA.
- Good working knowledge of Claims processing, Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction Set EDI X12 837, 270/271, 276/277, 278, 834, 835, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
- Experience with HIPAA 4010 and 5010 EDI healthcare transactions and transition of ICD 9 to ICD 10 codes.
- Have good exposure to Facets and QNXT for claim processing.
- Have also worked on all the environments of QNXT and Facets which includes the Test Environment, Development Environment and Production Environment. Experience in performing GAP Analysis between AS IS and to be workflow models.
- Working as a liaison between business users, Partners, vendors and developers.
- Experienced in communicating directly with Stakeholder, SME's and end users to gather and translate requirements into detailed project development strategies for effective deployments.
- Leading JAD sessions and JAR sessions across projects.
- Experience in Elicitation techniques like surveys, interviewing, questionnaires, brainstorming, focus groups, and prototyping.
- Extensive experience in Business Requirements gathering and writing skills with expertise in developing and documenting Business Requirement document (BRD), Functional Requirement Document (FRD), Software Requirement Specification (SRS) across the deliverables of a project.
- Extensive skills in developing UML diagrams like Use Case diagrams, Sequence diagrams, Class diagrams, activity diagrams and swim lane diagrams, etc.
- Proficient in creating user stories, use cases, prototypes/wireframes and writing Business Requirement Documents (BRD), Functional Requirement Documents (FRD) and Requirement Traceability Matrix (RTM).
- Facilitate meetings for defining business requirements, User Acceptance Testing (UAT) and Business acceptance testing (BAT).
- Working knowledge of Structured Query Language (SQL) for data manipulation and retrieval from data ware house and transform it to required Database like DB2, Oracle and so on.
- Proficient in coordination of defect management and monitoring the status using HP Quality Center, Jira and Bugzilla.
Methodologies: Agile, Waterfall
Requirement management tools: QC, JiraProject management tools MS Project, MS Visio
Front-End tools: Microsoft Excel, Word, Power Point, SharePoint
Operation system/platform: MS Windows 2010, 2008, 2003/XP/2000/NT
Confidential, Bloomfield, CT
- Analyze change requirements for Providers, Contracts and Claims processing modules configuration in QNXT system for Medicaid and Medicare Advantage for AL, FL, GA, IL (ICP &MMAI), IN, MD, MS, NC, SC, PA and TN plans.
- Spearheaded client implementation and integration projects for Medicare's Chronic Care Management (CCM), working directly with EMR and EHR vendors and end users at physician practices. Heavy focus on HIPAA, HL7, C-CDA, Web Services, SOA, scalability and performance.
- Defined and documented the vision and scope of the project.
- Creating GAP analysis report and conducting Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
- Used a mix of SDLC Process and Agile Methodology while working on the projects in order to be able to deliver in a phased approach and meet the deadlines.
- Gathered requirements, developed Process Model and detailed Business Policies.
- Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
- Participated in various meetings and discussed Enhancement and Modification Request issues.
- Attended and facilitated weekly meeting to discuss progress and modification to plans due to change in business requirements.
- Created/authored documents like High Level Requirements and Detailed Level Requirements document.
- Created documents to address simple work efforts that required less than 80 hours of design and testing before implementation to address new business requests.
- Configure Providers (Individual, Group and IPAs) per Provider Change Management application (PCMA) load information and utilize Contracts module to identify appropriate contracts and networks for non/credentialed providers using legacy fee tables crosswalks, signed contracts, NPI Registry, EDI 835 & 837 Claim image (1500 & UB04).
- Utilize Member module to verify eligibility, benefits and PCP assignment to maintain accuracy.
- Update and analyze Claims 101 edit errors for missing contracts in an accurate and timely manner to avoid penalties.
- Ensure system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
- Work closely with IT staff to automate testing processes whenever possible to reduce configuration errors.
- Correct and maintain audit errors log to ensure high accuracy and productivity.
- Provide analysis and conduct testing for change requests, software releases, and fixes.
- Ensure departmental documentation, daily and weekly reporting is being completed timely and accurately.
Environment: Agile, SQL, MS Word, Excel, Access, Lotus Notes, File Viewer, Web Client, Clear Quest, Requisite Pro, MS Visio, SharePoint.
Confidential, Virginia Beach
- Assisted project manager to prepare business document, project schedules, resource allocation, project duration and cost by using MS Project.
- Communicated Project Requirements, Business Issues, Solutions and made recommendations.
- Gathered and analyzed requirements for PRM integration.
- Working as business system analyst for migration of SSB (State Sponsored Business) Health Plan business from Diamond system to Confidential Group System (PBM Platforms).
- Performed Extensive Data Analysis on Oracle and MS Access Databases.
- Developed Source to Target Mappings using Excel Spreadsheets and maintained them by Versioning.
- Implementing a fully integrated and efficient system for maintaining PDE (Medicare Part D) data in a single Database that has the capacity to interface and query data from primary claims adjudication systems.
- Extensively tested claim data using SQL from different prospective. Dealt with following table as BA prospective: Claim, Claim Line, Claim Line CDHP, Max Revision, Claim Paid, Provider, Pharmacy, Member Product Enrollment and Pharmacy MED D.
- Involved in EDI Process for electronic document/data transformation.
- Working on Pharmacy Claims/Rx claims, Claims adjudication,, Eligibility, Prior Authorization, Accumulators, Drug Step edits, PHI and different managed care products like POS, HMO and PPO.
- Working directly with Project managers, Business Team, Technical team, QA Team to analyze and eliminate errors.
- Involved in all phases of system development including requirement gathering and analysis, Designing, Development, Testing, Implementation, deployment, maintenance.
- Gathering Requirements from business, created BTRDs, BRDs, TDD and supported technical and testing team.
- Documenting all system changes and request for changes (RFC) for user access using change management forms.
- Used MS Excel to create test cases and import the data to Quality Center.
Environment: Agile, MS Visio, Word, Excel, PowerPoint, SQL, SharePoint 2010, MS Project
Confidential, Dover, DE
- Built an Information Security Risk Assessment (ISRA) for the secure exchange of health insurance data as part of the Affordable Care Act (ACA)
- Responsible for implementing payers onto the Health Care Exchange (HIX) for the Affordable Care Act.
- Responsible for updating clients with provider information within MMIS on a weekly basis by running queries and exporting data in a defined file formats.
- Thorough knowledge of ICD 10 codes and CPT codes for both Mental and Medical Health and worked extensively with Inbound and outbound 834 Transactions processing systems.
- Compile, validate and report system-wide metrics to attest meaningful use of EHR to the Centers for Medicare and Medicaid Services.
- Created, altered and implemented T-SQL Stored Procedures for the use of processing consumer data and developing new web delivered tools.
- Used Data warehousing skills including ETL and end-user access issues.
- Planned the entire Data Warehousing initiative from requirements gathering, analysis, design, identifying and analyzing the source systems, to data quality, to ETL, and to the end user data access.
- Provided release management strategy checklists and change management techniques.
- Presented and assisted end users for and about the new system.
- Generated reports using SQL Server Reporting Services (SSRS), and MS Excel spreadsheets.
- Involved in Source Data Analysis, analysis and design mappings for data extraction.
- Also responsible for Design and Development of SSIS Packages to load the Data from various Databases and Files.
- Design, deploy, and maintain various SSRS Reports in SQL Server 2012.
- Collaborate with federal clients (CMS, NIH, ONC) and standards development organizations such as HL7 to develop
- Responsible for UAT project planning and Performed Regression, UAT, Integration, User Interface, GUI, and Usability Testing and wrote test cases and test scripts, execute test scripts and analyzed outcomes and conducted research on IT requirements and business requirements in UAT areas.
- Validated Test Cases and Execute test cases in CURUM for UAT Test Scenario.
- Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
- Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA)
- Developed Schemas of EDI X12 Claims (837) and Eligibility forms in XML. Involved in creating sample mappings for the conversion of EDI X12 transactions code sets.
- Lead SCHIP, CMS request to be able to identify the Medicare eligible candidates.
- Generated and maintained SQL Scripts to perform back-end testing on the oracle database. Produced customer functions, complicate SQL commands in Business Object Enterprise XIR2 and Oracle 10g, Crystal Reports XI environments.
- Assist clients in resolving billing issues for Medicare, Medicaid, and private insurance.
- Acted as an SME on various subject areas including state reporting, death benefits, Medicare, Bill review and RX eligibility.
- Troubleshooting utilizing CPT4 & ICD 10 codes and Managed HL7 interfaces for PM/EHR software and Lab computers and performed requirements gathering, business process mapping and re-engineering as a part of health exchange readiness efforts for leading public health plan entering state HIX market.
- Involved in projects to design a state-customized Financial Management solution for Health Insurance Exchange (HIX)
- Developed various test cases for testing HIPAA 8371/P/D 834/835 and 276/277.
- Developed EDI specifications and applications structures for data feeds and mappings for integration between various systems, including XML and performed back-end testing on the Oracle database by writing SQL queries
- Handle the tasks of helping the organization staff in planning data sets for UAT.
- Created Test Strategy Planning (TSP) and assisted testing team to implement test plans during UAT kickoff.
Environment: SQL, MS Word, Excel, Access, Oracle, DB2, Lotus Notes, File Viewer, Web Client, Clear Quest, Requisite Pro, GEM, MS Visio, SharePoint.
Confidential, Pleasanton, CA
Business Analyst / Quality Analyst
- Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
- Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
- 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, 270, and271.
- Responsible for GAP analysis of ICD9-ICD10.
- Involved in Mapping Disease codes from ICD system to EHR.
- Validated all health data in EHR as per HIPAA 5010.
- Involved in testing Diseases codes and health information in EHR.
- Helped in improving EHR as per customer service perspective and developed user guide for our customer support team.
- Involved with ICD10 implementation testing.
- Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
- Performed Unit Testing and User Acceptance Testing and documented detailed defects.
- Developed Test Cases to validate the requirements and documented the Traceability Matrix for Test Cases and Requirements
- Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements
- Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams using UML and Business Process Modelling.
- Developed business process models in RUP to document existing and future business processes.
- Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
- Provided management support to the off-shore End to End Integration / Regression Test Team
- Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements
Environment: UML, RUP, HEDIS, Rational Rose, ASP.NET, Requisite Pro, MS Visio, RUP, MS Project, SQL, Oracle, ETL, MS Access, MS Excel and MS Word.
Confidential, Roanoke, VA
- Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
- Created Use-Cases and Requirements documents to document business needs.
- Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts and other potential users of the application.
- Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
- Created and maintained the Requirements Traceability Matrix (RTM).
- Worked on Guidewire, extensively worked on Guidewire Policy center & Guidewire Claim Center
- Used GuideWire software to track the claims of the policyholders.
- Guidewire was specifically used by the team to implement the enhancement to expedite the claim process for unregistered users
- Used Guidewire to upgrade the current Claim system to track the claim of the policyholders and third party applications
- Involved with the testing team to check the augmentations done previously using Guidewire.
- Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
- Maintained documents and the effect of proposed changes on the project schedule and costs.
- Used Rational Clear Quest for bug reporting.
- Documented the Use Cases and Activity diagram worked on COTS Integration and Application Architecture design. Created and maintained workflow plans and business process flows using MS Visio 2013.
- Worked directly with software engineers to ensure clear communications on requirements and defect reports.
- Designed and developed scenarios based on business requirements.
- Developed requirements integrating E-R diagrams and designed the testing process flows.
- Followed the RUP methodology for the entire SDLC.
- Used the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of the Software Development Life Cycle.
- Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
- Validated the scripts to make sure they have been executed correctly and meets the scenario description.
Environment: Windows2000, Rational Rose, Guidewire, Rational Unified Process, Rational Clear Quest, Oracle, and Microsoft Project 2000.
Confidential , Dallas, TX
- Designed, reviewed and executed test cases
- Interacted extensively with Business and Technical leads to review and obtain sign-off of the test cases across all business functional areas - Provider, Claims, HL7 data, LIMS, Customer Service, Products, Group/Member, Billing/Finance, Security and Utilization Management
- Tested the X12 HIPAA / EDI transactions (270, 271, 837, 834, 835, 276, 277)
- Executed SQL Queries to ensure data accuracy before and after applying transformation rules
- Worked Extensively on ETL process using SSIS package.
- Used queries for manipulation of test data
- Performed data profiling for data quality validation
- Coordinated UAT with business users
- Assigned and coordinated tasks with offshore test team
- Documented defects, bug fixes and analyzed defect injection rates using HP Quality Center
- Provided Test and defect status reports and involved in defect discussion meetings
Environment: MS SQL Server, SQL, ETL, HTML, XML, MS Excel, QTP, QC, Windows and Linux environment.
Confidential, Dallas, TX
- Perform daily charge reconciliation to ensure all charges are entered into patient accounting system. Maintain daily Excel based workbook to record/track discrepancies Assist Billing/Coding Manager in conducting root cause analysis to prevent systematic recurrence of edits/issues
- Knowledge of the complete 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.
- The process included importing claims into Facets that had been adjudicated and setting them in a "PAY" status so that a payment cycle could be run to create checks on Facets.
- Defined Data Maps to validate and customize Claims daily load into FACETS for processing the transactions.
- Involved in various types of Audits and the Financials involved through different stages.
- Gained Compliance audit experience due to exposure to the legal/audit consulting groups.
Environment: MS Word, MS Excel, SQL, MS Access, MS Project