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Sr.business/edi Analyst Resume

Bethesda, MD

PROFESSIONAL SUMMARY:

  • Business/EDI Analyst with over 8 years of strong healthcare industry experience in business data modeling, software requirement analysis, process modeling, process flow and quality assurance skills
  • Exceptional knowledge in testing phases with state HIX projects.
  • Thorough knowledge of ICD - 9, ICD-10 codes and CPT codes for both Mental and Medical Health.
  • Very good experience on EDI testing and ITS systems.
  • Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets and HL7.
  • Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
  • Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Scrum and Agile.
  • Worked on Data migration, Reports Implementation, letters, Inbound/outbound Interfaces and Facets Extensions.
  • Experience in using test management and defect tracking tools Quality Center, Test Director, and JIRA for tracking the defects and reporting the defects.
  • Involved in creating documents related to Facets billing with setting up Entities with in a particular group based on group profile.
  • Experience in executing the test cases and test scripts in different phases of testing like GUI testing, functional, regression, integration testing, system and user acceptance testing.
  • Responsible for setting up Billing frequency, premium invoicing.
  • Expert in insurance-payor systems - Claims, Billing with backend data mapping, data integration
  • Experience in executed all test cases in all phases of testing like GUI testing, functional testing, regression testing, integration testing, system testing, end-to-end testing and user acceptance testing.
  • Experience in using PL/SQL for implementing data-intensive and complex business logic
  • Experience in QA verification and QA validations to ensure the quality assurance control.
  • Proficient in writing the QTP scripts using VB script and executed through QTP.
  • Organized many joint application developments (JAD) sessions and joint requirement planning sessions (JRP), walkthrough, Interviews, workshops and rapid application development (RAD) sessions with end-user/clients/stake holders and the IT group.
  • Extensive experience in reviewing and understanding of business and testing requirements and writing detailed test plans, test cases, and test scripts.
  • Experience on web services like SOAP UI and WSDL elements and knowledge in SOA.
  • Involved in entire QA life cycle (SDLC), which includes design, development and implementation of the entire QA process for the relational database, web and client/server, IBM mainframe applications.
  • Excellent working knowledge of designing and implementation of all QA test strategy plans and automated test solutions for client/server and web applications with Mercury Interactive Test Suite (LoadRunner, WinRunner, QuickTest Pro (QTP) and test Director).
  • Performance testing expertise in developing performance test plans, test strategy, load modeling, performance metrics and performance analysis

TECHNICAL SKILLS:

Business Tools: Rational Suite, MS Visio, MS Project, MS Access, MS Office Suite, and Business Object (Crystal Reports).

Business Skills: Business Definition Requirements, Business Process Analysis, Gap Analysis, Use Case Modelling and Analysis, Business Environment and Market Research Analysis.

Methodologies: RUP, Agile, Waterfall, UML and Business/Data Modeling.

Testing Tools: Win Runner, Soap UI, Load Runner, ALM, MDE, Compass, UFT, FACETS, Quality Center, Test Director, Quick Test Pro (QTP), QNXT, PR Tracker, PowerStepp

Operating Systems: Windows 7/XP, Mac OS X and Linux.

Databases: SQL Server 7.0, Access 2000, MS SQL Server

Languages: UML, C, C++, HTML, Java, and SQL

PROFESSIONAL EXPERIENCE:

Confidential, Bethesda, MD

Sr.Business/EDI Analyst

Responsibilities:

  • Business System Analyst for outsourcing all paper claims and correspondence documents to an outside vendor. Defined requirements for receiving 837 claims files and MACESS files into our imaging software and work flow software
  • Worked extensively through Agile development methodology by dividing the application into iterations.
  • Used JIRA for agile planning, issue management, project timelines estimation, backlog grooming and reporting.
  • Wrote user stories, maintaining product backlog, planning release backlog and sprint backlog, prioritizing the PBI, and planned on how to execute user stories.
  • Created Use Case diagrams, Sequence Diagrams, Activity Diagrams and Class Diagrams using UML and Business Process Models using MS-Visio.
  • Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Involved in documentation of NDC and NCPDP Billing Request and Reversal for the pharmacy claim transactions.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid claims and NCPDP claims.
  • Participating in processing of requests for medical services and pharmacy services submitted via DDE or HIPAA 837 EDI and NCPDP submissions testing, integration testing, system testing, end-to-end testing and user acceptance testing.
  • Responsible for working on Mapping of EDI files with Facets back end database.
  • Responsible for creating documents regarding the configuration of billing module with detailed regarding GL, AR/AP generation method, Fees and discount etc.
  • Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems
  • Responsible for Business Process Management (BPM) for development of various projects.
  • Analyzed the impacts of HIPPA 5010 project on inbound 837 claims.
  • Collaborate with business partners and developers to create EDI X12, NCPDP D.0 and proprietary encounter submission files.
  • Created SQL scripts for different frames of testing.
  • Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
  • Defined the current clinical and financial business processes and practices.
  • Participated and contributed in daily scrums, Sprint review and Sprint retrospective meetings.
  • Performed manual testing by building 837 claims, converting them into EDI file, uploading them into mainframe region and doing error resolution & testing for 5010 requirements & NPI crosswalk.
  • Worked on Data Mapping to map Facets data to outbound eligibility extracts.
  • Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Conducted the Functional, System, Integration, Regression, UAT, performance Tests of the Application.
  • Proficient in data warehouse, database concepts and methodologies.
  • Develop, design & implement department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
  • Analyzed the ICD conversion information provided by the CMS and gained understanding of ICD-9 versus new ICD-10 codes sets.
  • Verified and Reported of all issues/defects from small to big raised by UAT team
  • EDI file testing for checking the HIPAA 5010 (X12) compliance of the inbound 837 claims.
  • Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
  • Performed Data Mapping to map the EDI 834 data to XML.
  • While working on requirements of the 835 HIPAA project, jumped half way in the 820 report project, continued working on 835, 834, 276 / 277 and HIPAA EDI Transactions across enterprise
  • Worked on FACETS claims processing, payment adjustments, claims inquiry, benefits,
  • Assisting the project manager in creating detailed project plans and scheduling and tracking project timelines.
  • Worked on CMS (Centers for Medicare & Medicaid Services) requirements within the project.
  • Responsible for Business Process Management (BPM) for development of various projects.

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, JIRA, HL7, MS Office, SQL Server, MS FrontPage 2003, MS Visio, MS Access, EDI,UML

Confidential, Phoneix, AZ

Sr. Business/EDI Analyst

Responsibilities:

  • Reviewed Business Requirement Documents and Functional Requirements.
  • Prepared GAP documents involved with 834, 820 transactions in collaboration with other team members.
  • Gathered requirements, developed Process Model and detailed Business Policies.
  • Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835,834 EDI transactions
  • Captured all HIPAA-related EDI data in the repository using FACETS.
  • Accepted inbound transactions from multiple sources using FACETS.
  • Supported integrated EDI batch processing and real-time EDI using FACETS.
  • Responsible for creating documents regarding the configuration of billing module with detailed regarding GL, AR/AP, generation method, Fees and discount etc.
  • Responsible for setting up Billing frequency, premium invoicing.
  • Maintained Requirement Traceability Matrix (RTM) to make sure that test plans were written for all the requirements
  • Coordinate detailed End-to-End Test Cases and design steps walkthroughs and ensure signoff by stakeholders.
  • Develop, coordinate and support Information Technology Division on all operational requirements of FACETS claims processing system and production management.
  • Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Worked on FACETS claims processing, payment adjustments, claims inquiry, benefits,
  • Develop, design & implement department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
  • Performed Static, functional and end-to-end testing on agent portals used for MA HIX.
  • Worked on FACETS claims processing, payment adjustments, claims inquiry, benefits,
  • Analyzed XMLs extracted from executed E2E scenarios for data being sent and received from dell.
  • Involved in writing PL/SQL commands in doing test data validation.
  • Worked in testing the professional, institutional claims processing and adjudication and validate data with facets.
  • Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems
  • Attended daily UAT stand-up meetings with internal UAT Analysts, Leads, Managers and PMs
  • Experience with test setup, defect management and maintenance in HP quality Center
  • Extensive knowledge working with tracks that included Plan Management, Plan development, enrollment and Billing, and Regression testing.
  • Worked on Data Mapping to map Facets data to outbound eligibility extracts.
  • Produce daily and weekly testing status reports and communicate to upper management.
  • Wrote test cases and test scripts, execute test scripts and analyzed outcomes.
  • Performed defect testing for individual tracks that worked with notices, UI/UX and eligibility verification.
  • Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
  • Performed web applications testing such as functionality, usability, interface, compatibility, performance and security testing.
  • Develop, design & implement department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
  • Tested the outgoing links from all the pages from specific domain under test.
  • Validating the site for HTML syntax errors and defects for website functionality.
  • Data testing for integrity and errors for edit, delete and modify forms or do any DB related functionality.
  • Used the Functional testing tool SOAPUI, to perform Web Service Testing.
  • Tested Web Services, XML, WSDL using SOAPUI tool. Modified end points when the work was performed on different servers and different versions of Web Services
  • Performed interface testing between serves to see if they were being executed properly.
  • Identify project applications and business areas to be involved in testing.
  • Performed white box, black box, and usability testing.

Environment:: Agile/Waterfall, MS Office Tools, Windows XP, DB2, Quality Center, MS SQL, UNIX.

Confidential, Phoenix, AZ

System Analyst/ICD10 Tester

Responsibilities:

  • Responsible in providing Business Requirement Document (BRD) and Functional Requirement Document (FRD).
  • Analyzed inpatient and/or outpatient medical records using International Classification of Diseases, Ninth Revision (ICD-9/10) and Update ICD-9 and CPT code changes.
  • Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions. Worked specifically on EDI Health Care Claim Transaction set (837)
  • Maintained reimbursement summaries from third parties and compare with clinic fees, Updated reimbursement regulation, Notify Business Manager of significant changes, conduct periodic medical record audits to ensure documentation is consistent with billing.
  • Remediated all custom codes, inner/outer extension impacted by ICD10 by identifying and creating user story for Developers in Team Foundation Server (TFS).
  • Well-defined and produced inclusive, accurate conversions of ICD-9 codes into equivalentICD-10 codes with the option to adjust system application for ICD-10 specificity using GEMS.
  • Assisted with the User Interface (UI) prototypes to capture and validate requirements and spike solutions to the occurring problem.
  • Tested claim billing processes as well as other healthcare processes such as enrollment, eligibility, and claims-to-remittance adjudication processes.
  • Analyzed claims processing syntax and business rules for HIPAA 4010 and 5010 to validate loops, segments, elements, qualifiers and code sets.
  • Followed the Waterfall methodology during the entire SDLC.
  • Created EDI Export and Import processes for the EDI Trading Partners, Payers/Vendors.
  • Created Test cases, and test plan from stage to production in MS SQL.
  • Explicit supported in the creation of Companion Guide.
  • Performed UAT testing for ICD10 and legacy testing for HIPAA 4010 and 5010 projects for HIPAA requirements and compliance mandates.
  • Performed Unit testing and documented it using Excel, created Artifacts and listing for UAT validation, and validated Use Case Documents.

Environment: Share Point 2010, MS Visio 2010, Rational Rose, GAP Analysis, UML, Use Case Analysis, SQL Server, Microsoft Office Suite, Quality Center, JSP, Java Script, XML, HTML, Agile, and Scrum Master, test Director, Rational Unified Process (RUP), MS Access, and DB2.

Confidential, Philadelphia, PA

Business System Analyst

Responsibilities:

  • Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
  • 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
  • Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA transactions 837/835, 834, 276/277, 270/271 testing.
  • Tested and implemented HIPAA 4010 and 5010 and ICD 10, version for all EDI transactions.
  • Prepared master test plan covers both the HIPAA 5010 compliance system impact documentation based on 5010 changes and ICD-9 to ICD-10 migration.
  • Performed requirement analysis by gathering both functional and non-functional requirements based on interactions with the process owners and stake holders and document analysis, represented them in Requirements Traceability Matrix (RTM)..
  • Prepared high level end to end use cases and individual use cases for each 5010 transaction.
  • Facilitated four-hour long round table discussion with most HR directors, managers and analysts along with QA manager to get their input ad-hoc UAT in the project.
  • Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
  • Prepared High Level Test Strategies for the both the 5010 Compliance and Facets 4.61.
  • Reviewed technical specs together with the team of two developers.
  • Executed all test cases in all phases of testing like GUI testing, functional testing, regression testing, integration testing, system testing, end-to-end testing and user acceptance testing.
  • Wrote test cases in MS Excel for user registration, access to training material, and activity log-in, reviewed the test cases and finalized.
  • Environment: Windows, Oracle, PL/SQL, MS-Project, MS-Office Suite, MS Visio, Rational Requisite Pro, Clear Case, Clear Quest, MS Visual Source Safe, Test Director and Quick Test Pro (QTP).

Confidential, Philadelphia, PA

Systems Analyst

Responsibilities:

  • Performed pivotal role as a Systems Analyst in multiple projects and handled three releases at the same time.
  • Release one and two were web-based service application developed for streamlining office workflow processes involved in Electronic Data Interchange (EDI) transactions and benefits in claims management cycle based on HIPAA Guidelines.
  • Release three was based on reporting the policy premium. There were seven reports, which were generated in Brio portal.
  • Maintained good understanding on ICD-9 and ICD-10 upgrade as well as 4010A and 5010 State Companion guides, 4010A to 5010 side by side changes document, business requirement document (BRD), functional requirement document (FRD) and also good understanding on each transaction implementation guides.
  • Generated test cases in Claims Analyzer Editor Professional to ensure unification with CPT-4 and ICD-9 codes.
  • Tested and Validated SOAP request and SOAP response messages.
  • Identified each 5010 transaction files change and prepared the severity levels like, high level, medium level and low level and prepared the line of estimation by using the estimate tool.
  • Tested the claims system, Facets 4.41 and 4.51, through the 837 HIPAA X12 Formats (837D, 837P, 837I).
  • Involved in creating test cases for IDC-9 codes and 837,270,271,835,820 transactions and validating the EDI files.
  • Performed manual testing as well as automation testing with SOA test tools such as SOAP UI.
  • Worked on agile methodology using Scrum.
  • Tested the universe functionality by writing complex SQL queries in Oracle and verifying the results against the Universe.
  • Used Facets ITS sub system to easily send, receive and manage data regarding claims, provider, membership, and fee-for-service/capitation billing.
  • Clarified QA team issues and reviewed test plans and test scripts developed by QA team to make sure that all requirements will be covered in scripts and tested properly.
  • Worked with the EDI team to validate the input and the translated files based on the mapping guide.
  • Identified effect of new changes on existing applications like Edifecs (X-engine, Spec Builder).
  • Developed budget planning report and timelines of the project by conducting walk-through sessions and meetings involving various leads from development, QA and technical support teams.
  • Environment: Rational Suite (Rose, Requisite Pro), Windows XP/2000, SQL, XML, HTTP, MS-Project, MS-Office Suite, MS Visio, Agile/Scrum, Win Runner, Load Runner, Test Director (Mercury Interactive), Java and Oracle.

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