SUMMARY:

• Results - driven, versatile consultant with over 6+ years’ experience as a Business Analyst.
• Specialized in Healthcare, Insurance, Risk and Compliance, Document management.
• Good knowledge of Business Analysis methodologies, Iterative and Incremental Software Development Life Cycle (SDLC) using Rational Unified Process (RUP).
• Exposed to Agile methodology
• Preparation ETL specifications and Creating Mappings in Informatica PowerCenter/PowerMart 5.1.0 for the incoming data.
• Extensively used ETL to load data from different sources
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence)
• Maintained Gitlab repositories, JIRA bug tracking system. Created custom JIRA workflows
• Install, configure and maintain JIRA bug tracking system
• Experience in CMS and MMA Guidelines.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Coordinate changes with customers, vendors and users for EDI..
• Proficient in gathering business and technical requirements from both formal and informal sessions through interviews, NetMeeting, questionnaire, video conferencing, JAD sessions and conference calls.
• Strong knowledge of Use Cases, Sequence Diagrams, Collaboration Diagrams, Activity Diagrams, and Class Diagrams.
• Extensive hands-on and HealthCare management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support the Medicaid Management Information System (MMIS) as well as day-to-day business operations.
• Hands on knowledge of various Health Care standards/requirements like HL7, CCHIT, Meaningful Use & Stimulus Program, HITSP, PQRI, HIE, CQM, DICOM, ISO, IEEE.
• Experience in developing Test Plan and Test Cases as per the business process requirements to match the functionality requirements and UML diagrams.
• Data mapping on Enrollment Module (EDI 834) of FACETS.
• Worked on Data migration, FACETS version upgrades 4.51/4.71,5.01 Reports Implementation, letters, Inbound/outbound Interfaces and FACETS Extensions. Implemented EDI transactions 837, 835, 270/271, 276/277 and 834.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Possess very good organizational skills, with the ability to multi-task and deal with shifting priorities.
• Experience in Claims Processing, Claim encounters and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
• Experience in EDI (270,271,835,834,837) transactions.
• High-level understanding of a health care claims processing system such as MMIS.
• Sound analytical and problem solving abilities.
• The scope of the project was the conversion of EDI format from formats to the format as per HIPAA compliance
• Expertise in the EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAAfor 837, 270/271, 276/277, 835, 834 EDI transactions.
• Worked on healthcare standards such as HIPPA 4010, 5010, DICOMM, CPT, ICD-9 and SOAP.
• Expertise in ICD-9 to ICD-10 Conversion.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile
• 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.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR (continuity of Care Record), CCD (Continuity of Care Document), NCPDP Script 8.1, ELINCS, and CDA.
• Worked on various Professional billing and Hospital billing products.
• Experience in working with HHS, CMS or Medicaid Programs, RHIOs, IHDNs.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA 5010 code sets, ICD-9, ICD 10 coding and HL7.
• Data mapping on Enrollment Module (EDI 834) of FACETS.
• Knowledge on medical necessities, software validation and healthcare compliance auditing.

TECHNICAL SKILLS:

Methodologies: RUP, Agile, CMMI, CMM, Six Sigma, OOAD, UML, Business Modelling, Process Modelling and Data Modelling.

Office Tools: MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, Lotus Notes.

Process: MS Visio, Rational Rose, Rational Requisite Pro, Smart Draw, Clear Case, Clear Quest.

Testing Tools: Test Director, Quality Centre, Win Runner and Selenium

Operating Systems: Windows 7, Vista, NT/2000/2003/ XP/98

Quality Management: HIPAA, CMMI, CMM, Six Sigma, TQM

Languages: C/C++, Java, SQL, PL/SQL, HTML, XML

Database: MS Access, SQL Server 2000, Oracle 9i & 10g, Teradata

Other Tools: Macromedia Dream Weaver, Macromedia Flash and Adobe Photoshop.

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Business Analyst

Responsibilities:

• Extensive experience in Conducting Market Research, Feasibility Studies, Data Analyses, System Analyses, Gap Analyses, and Risks Analyses.
• Gathering market data including real time and historical price data, financial data, and trading news using financial data source named Bloomberg.
• Responsible for gathering requirements from users in operations group and performing data mapping for the application, confirm and vacillating the requirement at time of BA testing.
• Solid Experience in developing Scope/Vision Documentation and Project Plan, as well as tracking Project Process, and manage resources to ensure successful delivery
• Deep understanding the Business Flow of Investment Banking, and extensively involved in Portfolio management and analyses, Mutual Funds, Securities trading.
• Developed test plans with QA team and helped test every scenario using Mercury TestDirector Tool for system testing
• Efficient use of MS Project for planning and status reporting.
• Deep understanding of Structured System Development Methodologies
• Collaborated with External Auditors and documented SOX compliance requirements
• Assisted Project Management in developing Scope/ Vision Documentation and Project Plan, tracking project process, and developed Risk Mitigation Plan
• Currently leading, coordinating EMR/EHR (iHelix Suite) implementation to achieve meaningful use stage
• Extensive success in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) in an SOA environment.
• Scheduled the ETL jobs daily. Weekly and monthly based on the business requirement
• Researched, Analyzed, designed, developed Java Web Services Service Oriented Architecture (SOA).
• Worked extensively in Data Analysis, Data Reconciliation and Data Mapping for ETL process
• Used MS Visio for Process modelling and Business Process flow diagrams.
• Facilitated mini JAD sessions to assess and refine business, functional and system requirements for TANF, Food Stamp and Child Care program enhancements/development
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication)
• Tested HIPAA regulations in Facets HIPAA privacy module
• Met with stakeholders to identify requirements to modify Federal TANF reporting system.
• Used SoftTest software with pseudo code to ensure test cases covered all branches of project's code impacting the system. (The system is an IBM mainframe based system that contains the master set of customer information used to bill customers.)
• Being able to adapt and work efficiently in an agile environment where the cumulative Standard Operative Procedure (CSOP) and Policy directives and decision Matrix documents were in process and unstable during the initial phase of the project.
• Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them.
• Served as Healthcare Informatics Analyst for nation's largest touch screen and clipboard vendor with partnerships including various EMRs, GE PACs, GE Centricity, Imagecast Radiology, Meditech, Seimens
• Tuned the Performance for ETL jobs by tuning the SQL used in Transformations and fine tuning the database.
• Extensively worked in the performance tuning of programs, ETL procedures and processes.
• Performing business analysis, software validation and testing for client/server, multi-tier and web-based applications for EMR and commercial business for managed healthcare plans and Industries
• Worked on automating Forward Curve calculation application that allowed internal users and managers to predict the daily, monthly, quarterly and annual commodity price (green energy) based on market value and previous years data
• Worked intensively on FACETS 4.6.1 for audit trails made on the used account and check and store information related to the HIPPA authorizations
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Set up market data including zero curves, correlation matrices, dividend curves, etc., and the underlying financial instruments and then set up derivatives pricing parameters and trade capture options that drive the valuation of trades based on the market data to configure and test the system
• Ensured that the data repository was setup in case of emergency or unavailability of data.
• Solid experience in calculation of the Greeks (Delta, Gamma, Vega, Theta and Rho) in the simulation test of the system.
• Solid Experience in Collection, analyses, and documentation of User Requirements, as well as Organizing interviews, User meetings, workshops, JAD sessions and requirement elicitation sessions
• Proficient in creating Use Cases, Use Case Diagrams, Activity Diagrams etc.
• Expertise in development of High level design, Conceptual design, Logical and Physical design for Database, Data warehousing and many Distributed IT systems
• Assisted business users in identifying functional gaps, and developed detailed FSD for the gap
• Developed test plans with QA team and helped to develop test cases for system testing, integration testing and performance testing.
• Provided business and mapping expertise during a transition of the EDI applications from the GXS Application Integrator (AI) to GIS.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations
• 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.
• Tested the HIPPA EDI, 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.
• Scrum Master for multiple IT teams. Conduct project management duties in accordance with Agile / Scrum methods and best practices
• Capture Feature/Function information at varying levels of granularity and document them in a requirements management tool (e.g. Microsoft TFS, JIRA, etc.)
• Familiarity with a requirements management tool like MS Team Foundation Server, JIRA or the like
• Helped lead the transition of Requirements Management in the Business Analyst Team to the agile methodology by creating and managing user stories and Requirements Traceability Matrices in the JIRA toolset.
• Provide technical, business, management expertise, and support the Confidential and Centers for Medicare and Medicaid Services \(CMS\) in building and maintaining a comprehensive enterprise architecture program
• Work with CMS business owners to define their target goals and propose alternative business solutions
• Conducted UAT to confirm that all derivative products can successfully processed during the trade life cycle

Environment: Rational Requisite Pro, Clear Quest, Diamond, Facets, ASP.NET, VB.NET, C#, SQL SERVER 2000, IIS, XML, Mainframes TSO, JCL, DB2, MS Visio, Agile, Cobol, CICS, MQ Series, Facets, Lotus Notes, SOAP UI,UNIX, Windows 2000, Mercury Quick Test Pro*, Quality Center.

Confidential, Tampa, FL

Sr. Business Analyst

Responsibilities:

• Performed GAP analysis as pertains to management and claims processing to evaluate the adaptability of the new application with the existing process
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation & Verification process.
• Followed Agile (Scrum) SDLC methodology software development
• Developed Test Plans and Test Cases to test the GUI and workflow for Quality Assurance.
• Used Quality Center to plan tests, manages test assets, create and run manual and external scripts to check GUI and functional features of the AUT
• Involved with requirement gathering and analysis for the data marts focusing on data analysis, data quality, data mapping between ODS, staging tables and data warehouses/data
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Maintaining knowledge of Medicare and Medicaid rules and regulations and evaluating the impact of proposed changes in rules and regulations.
• Scheduled the ETL jobs daily. Weekly and monthly based on the business requirement
• Co-ordinating/Managing ETL Offshore team
• Testing the accuracy of iHelix inpatient EMR for Stage 1 meaningful use clinical quality measure calculation by using Cypress tool.
• Created Process Work Flows and responsible for preparing Functional Requirement Specifications Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming & developing questionnaires
• Efficiently worked alongside Project Manager and Lead Business Analyst to determine the Scope and utilized Rational Unified Process (RUP) and Agile (Scrum) System Development Life Cycle (SDLC) methodologies to coordinate and strategize concise solutions within a constricted timeframe involving multiple interfaces.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.
• Developed, designed & implemented department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization
• Track tickets related to EDI and provide periodic updates
• Troubleshoot issues with EDI partners and transaction processes.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Proficient in using Agile Scrum methodologies, performed roles of Scrum Master following sprint/standup sessions and used Excel extensively to write user stories, analyzed the Iteration Burn Down charts and reviewed defects
• Worked extensively through Agile development methodology by dividing the application into iterations
• Configured Process Models and Data Flow Diagrams by means of Swim Lane Diagrams, Sequence Diagrams, and Wireframes compliant to HIPAA 5010 standards for Electronic Data Interchange (EDI) Transactions 834 ( Enrollment), 835 (Enrollment of Benefits),270 (Benefits Inquiry), 271 (Benefits Responses), 276 (Claims Status Requests), 277 (Claims Status Notification), and 837 (Claims Processing) via Microsoft Visio.
• Used HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) and 820) standards
• Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for management
• Converting the Business rules into Technical Specifications for ETL process
• ETL Architect(Informatica and PL/SQL) /SME
• Currently leading, coordinating EMR/EHR (iHelix Suite) implementation to achieve meaningful use stage
• Involved in Up-gradation of HIPAA X12 4010 transactions to HIPAA X12 5010 and ICD-9-CM to ICD-10.
• Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers. Worked on ICD 9 codes and gathered future requirements based on ICD 10 codes. Managed creation of sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Report on project status to appropriate project management chain using Jira
• Document and track application failures and bugs using tools like Jira and Confluence
• Participated in changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage
• Owner of the business rules document, which documented the business rules across different systems.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Led and managed the User Acceptance Testing (UAT) for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Executed advanced level SQL queries to verify data integrity of the databases.
• Used Microsoft Word, Excel, Access and Visio as working tools.
• Involved in the development of Test Plans, Test Cases and Expected Results, and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Performed numerous data extraction requests using SQL scripts to prepare ad hoc reports.
• Performed Data Analysis, Data profiling and Data validation by writing SQL queries using TOAD
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehous
• Prepared and maintained EDI maps for different EDI transactions
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (, Billing, Provider, etc).
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Strong knowledge of Facets and actively involved in end-to-end implementation of Facets Billing, Enrolment, Claim Processing and Subscriber/Member module.
• Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS - enrolment and benefits.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Expertise in ICD-9 to ICD-10 Conversion
• As Interface Architect designed and developed Admission, Scheduling Charge messages flow and transformations for 50 applications such as Dietary, Oncology, Radiology, Professional Billing, Operating Room, materials management, HIM Coding, Lab, External Partner EMRs additional Hospital Billing Systems, and HIEs
• Worked with 837, UB92, UB04, CMS 1500 claims and HIPAA 835, 270/271, 276/277, 278 transactions
• Experience in CMS and MMA Guidelines
• 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)
• Strong functional expertise in the Healthcare Payer Area - claims, benefits, eligibility check, ICD10,HIPAA, CMS HCPCS Exposure to Health Care Industry standards like HIPAA / PHI Resolved data issues and updates for multiple applications using SQL queries/scripts
• Responsible for unit testing and working with System/Integration testing team in debugging/resolving any issues raised during testing.
• Created Data Flow Diagrams and Process flow diagrams for various load components like FTP Load, SQL Loader Load, ETL process and various other processes that required transformation.
• Conducted user pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity (mainly occur with EOPs, capitation rosters, PCP rosters, provider directory listings and some system generated letters)

Environment: Rational Unified Process (RUP), Agile (Scrum), HIPAA (5010), EDI X12 (834, 835, 270, 271, 276, 277, 837), ICD-10, Microsoft Project, Java, IBM Cognos, IBM Rational Suite, MS Visio, Word, Excel, PowerPoint, UML, XML, Microsoft Visio, Atlassian JIRA, Microsoft SQL, Microsoft Access, Facets.

Confidential, Newark, NJ

Senior Business Analyst

Responsibilities:

• Worked with the business users, management and IT users in gathering the technical requirements.
• Wrote Technical requirements, process flows and requirements traceability matrices to document and track the project progress.
• Responsible for communications and coordination between the various teams developing the various aspects of the project.
• Worked closely with the development team and offshore testing team to coordinate the testing
• Used MS Visio to create process flow diagram.
• Worked closely with business users and developers to translate business needs into technical requirements.
• Worked closely with the various development teams in identifying gaps and overlapping responsibilities.
• Wrote interface guides for various projects detailing the interface for the benefit of the production support team.
• Worked closely with third party developers in field mapping.
• Conducted interviews and sessions with users and gathered requirements.
• Extensive use of Microsoft Office tools to create and maintain the project documentation.
• Worked with the business to identify rules for the automatic generation of letters and correspondence for the Lead cases.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers. Worked on ICD 9 codes and gathered future requirements based on ICD 10 codes. Managed creation of sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Prepared and maintained EDI maps for different EDI transactions
• Created and maintained requirement documents for Facets for the different modules like Billing, Member enrolment and Claim adjudication.
• Tested and delivered Inbound/Outbound Facets UI interfaces.
• Worked on solving the errors of EDI 834 load to Facets through MMS
• Using FACETS for various health insurance areas such as enrollment, member, Products and other FACETS related modules
• Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system
• Analysis and Design of the FACETS data model to ensure optimal system performance and
• Coordinated the SQA testing with the offshore teams in the UAT and SIT environments.
• Identified gaps in the existing Lead survey and assessment, developed in Phase I, and documented them in the TRD and the survey specification document.
• Coordinated the business and development teams’ efforts in developing and testing the various features of the Lead DB project.
• Validated EDI X12 files for Connecture (CNX) and Center for Medicare System (CMS) using Ingenix Claredi and manually edited and fixed the errors to make it error free and ready for processing.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS
• Document the errors and balancing reports templates to be used in the various stages of the Lead DB program once it is in the production environment.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers. Worked on ICD 9 codes and gathered future requirements based on ICD 10 codes. Managed creation of sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Coordinated with the IT team and the development teams to identify the mode of communication, format of communication, file and folder naming convention to best suit the work flow and documented the same.

Confidential

EDI Analyst

Responsibilities:

• Interactions with the end users in order to generate the report required and to understand the business requirements relating to Medicaid program and Pharma.
• Involved in all phases of Software Development Life Cycle (SDLC).
• Used Informatica power center for extraction, loading and transformation of data in the data warehouse.
• Worked on the ICD 9 CM and 10 CM codes for billing purposes in pharma division.
• Obtained Data requirements, identified data sources, determined the content of data fields and created Data Mapping Documents and performed Data Extraction and Data Compilation using SQL queries.
• Worked on HIPAA X 12 transactions 4010 and 5010 Edi Transactions and test cases.
• Worked on hospital information systems and electronic medical records.
• Interacted with Informatica developers for designing and developing complex web intelligence, Business intelligence, Client and ad hoc reports for corporate data.
• Successfully designed and implemented statistical reporting processes for regular data collection and clinical data analysis. Analyzed safety and efficacy data from Phase II and III clinical trials.
• Met with physicians, nurses, billing and administrative personnel. Documented the clinical, financial and administrative business practices, procedures and workflows.
• Defined the current clinical and financial business processes and practices.
• Applied guidelines, standards and regulations such as HL7 CDA, CDISC, MedDRA, Code of Federal Regulations (CRFs) to clinical data modeling.
• Designed, authored, reviewed and revised Clinical Data Management Plans and Drug Safety Technical Reports are FDA 21 CFR Part 11 compliant
• Developed reports based on the Clinical Trial protocol
• Developed and executed SQL queries on claim records to validate reporting data
• Created and executed SQL Queries
• Worked with DBA and data architects on implementation of database changes.
• Documented technical services with desktop and other technologies and worked on analyze business and process flows.
• Coordinate changes with customers, vendors and users for EDI.
• Track tickets related to EDI and provide periodic updates.
• Troubleshoot issues with EDI partners and transaction processes.
• Identify possible solutions to EDI issues as they
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Provide EMR/EHR go-live support
• Experience in EMR, EHR, and HIE data interfaces and standards
• Worked with SME’s in Finance, Investment, Commercial and Personal banking to collect the Business process requirements, documented them in Business Requirement Document (BRD) and performed Business Process Re-engineering.
• Obtained Data requirements, identified data sources, determined the content of data fields and created Data Mapping Documents and performed Data Extraction and Data Compilation using SQL queries.
• Analyzed data flow requirements and developed a scalable architecture for staging and loading data and translated business rules and functionality requirements into ETL procedures.
• Analyzed business requirements and implemented technical solutions and assisted with local WAN, LAN, Server, desktop and other technologies.
• Developed test plans, test scenarios, test cases, test data to be used in testing based on business and user requirements, technical specifications.
• Interacted with DBA’s to understand the table’s schemas.
• Involved in the requirement gathering and analysis for implementing the data warehouse.
• Interpreted logical and physical data models with data modelers to determine common data definitions and establishing the referential integrity system.
• IRS, CMS, HHSC, HEDIS reporting
• Meets time sensitive deadlines from Medicaid health plans, state agencies, and CMS.
• Work with Business area to translate CMS, state government regulations, and NCQA requirements

Environment: Informatica PowerCenter6.2, MS SQL Server 2000, UNIX, PL/SQL, Agile