SUMMARY:

• 10+ years of industry experience as a Sr. Business Analyst with solid understanding of Business Requirements Gathering, Business Process Flow, Business Process Modeling and Business Analysis.
• Worked on Health Insurance Exchange (HIX), Health Care Reform (PPACA), ICD - 10, Medicare/Medicaid, EDI transactions (837,835,270/271,276/277,999)
• Worked on industry standard methodologies like Software Development Life Cycle (SDLC), RationalUnifiedProcess (RUP), CMM (Capability Maturity Models), and Capability Maturity Model Integration (CMMI) and Six Sigma and Rational Tools used during various phases of RUP.
• Expertise in developing Business Intelligence, data warehousing, and ETL applications using tools such as Tableau
• I have experience in both data and process analysis and modelling, with experience in functional change, MI/BI and data warehousing.
• Strong knowledge of dimensional modeling such as star and snowflake Schema.
• Excellent team player work in conjunction with testing, development and other teams in validation and testing complex scenarios and projects and in the maintenance of Quality Standards in Projects.
• Demonstrated expertise utilizing ETL tools, including SQL Server Integration Services (SSIS), Data Transformation Services (DTS), and DataStage and ETL package design, and RDBM systems like SQL Servers, Oracle, and DB2.
• Used NetworXPricer app to automate claims pricing & improving payment accuracy & process efficiency
• Adept at implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Sound knowledge of HIPAA, HL7, LO INC, ICD9/10 CM, EDI, HMO, PPO, Medicare, Medicaid, Sarbanes-Oxley Act (SOX).
• Worked on Facets (multiple versions) & conducted claims processing, billing, extract file creation, coordination of benefits etc.
• Familiar with current industry standards such as ISO, Six Sigma, and Capability Maturity Model.
• Performed Batch Jobs, front-end & back-end work pertaining to Facets (4.x,5.x), claims, membership & migration.
• Result oriented, committed and hard working with a quest to learn new technologies and undertake challenging tasks.
• Proficient in Developing and executing Test Plans, performing functional, usability testing and ensuring that the software meets the system Requirement.
• Excellent team player work in conjunction with testing, development and other teams in validation and testing complex scenarios and projects and in the maintenance of Quality Standards in Projects.
• Extensive experience with MS Visio for drawing flow charts and screen mock ups and MS Project for status reporting and planning.

TECHNICAL SKILLS:

Methodologies: Agile, Waterfall, RUP, UML, SDLC, Scrum, RUP, V-shape modeling, BPEL, BPMN

Change Management Tools: Rational Clear Quest, Rational Clear Case.

Business Modeling& VersioningTools: MS VISIO, Visual Paradigm, Rational Rose; Rational Requisite Pro, Rational Clear Case

MS Office: MS Project, MS Word, MS Excel, MS PowerPoint, MS Access

Programming Languages: Structured Query Language (SQL).

Operating System: Windows NT/98/2000/XP.

Databases: Access, Oracle 8i/9i/10g, Teradata, DB2, MS SQL Server 7.0/2000

Other known tools: Oracle Data warehousing, Informatica, Load Runner, Win Runner, Crystal Ball, Expert Choice, Core, Caliber

OLAP Tools: Business Objects XI, Cognos .

Testing tools: Rational Robot,RationalClearQuest Test Manager, HP Quality Center, Quick Test Test Professional, LoadRunner, WinRunner.

Apps & Webservers: Apache web server, Tomcat, Web logic 8.1, IIS

PROFESSIONAL EXPERIENCE:

Confidential, ND

Sr. Business Analyst

Responsibilities:

• Created test strategy& test cases/scripts for 837 P, I, D & UB92, NSF formats for legacy systems using Rational Test Manager.
• Created RFP’s, SOW’s & conducted Vendor Analysis for multiple systems pertaining to ICD-10.
• Developed and executed SQL queries for Redshift and Snowflake databases, through both the user interface and SQL Workbench.
• Worked on Oracle database for use as a data warehouse, designed data warehouses, Performed upgrades of the database and data warehousing software to new releasesManaging schema objects, such as tables, indexes, and materialized views.
• Worked in Scrum/Agile methodology developing user stories, acceptance criteria, working on product backlog items etc.
• Created Sprint Burndown charts, roadmaps, kanban boards, issue tracking, custom filters, customized workflows using JIRA
• Conducted meetings with CMS & state to coordinate HIM implementation including requirements, design, and testing & implementation documentation/management.
• Developed SQL queries to query the data present in databases stored in EDW.
• Integrated TrizettoNetworX with Facets for faster claim processing & conducted claims adjudication.
• Referenced CMS issued FFE Direct Enrollment API specifications document for developing Functional Specifications and System Requirement Specifications documents.
• Documented On-Exchange, Off-Exchange Enrollment Process flows via Activity Diagrams, Use-Cases, Sequence Diagrams etc. using MS Visio
• Transition monitoring as well as CLD processes from on-premise data sources to Snowflake/AWS cloud.
• Created and Validated Test Plan and Test case for NetworX Configurations
• Project involves creating a data warehouse to support the reporting requirements of EverBank Loan origination system
• Analyzed, developed Medicaid Managed Care Organization (MCO) & Primary Care Provider requirements for North Dakotans.
• Created Physical Solution Design Documents capturing technical details specific to enrollment validations, agent sales, shopper navigation, CMS FFM API specs & consumer ID generation as part of HIM implementation.
• Documented complex requirements, processes & rules pertaining to subsidies, tax-credits (APTC), eligibility, vendor system integration, EDI 834, & data-attributes etc. for HIM.
• Prepared complex process flows, activity diagrams, sequence diagrams pertaining to member enrollment, agent assisted sales, ICD-10 system impacts etc. for HIM and ICD 10 project.
• Wrote VB Script to do daily work & also performed testing by writing SQL queries using TOAD.
• Captured Scope, provider, medical policy, and product management etc. specific requirements for ICD-10 in RFP documents.
• Created BRD’s, Functional Specs, and Data Analysis & Data Mapping documents for ICD-10 impacting multiple systems.
• Produced Test Plans, Test Cases and conducted Regression Testing, SIT & UAT for ICD-10& Facets Migration work.
• Conducted Impact Analysis and data mapping/validation for ICD-9 to ICD-10 translation by accessing diagnosis master file.
• Conducted communications with providers to ensure readiness for ICD-10 i.e. developing provider readiness surveys etc.
• Performed GAP analysis & produced current process flow & future process flow diagrams & did the feasibility analysis.
• Analyzed Plexis& Facets as separate systems & did GAP analysis b/w the two along with TMG health & prepared BCBSND-TMG Health Detailed Gap analysis artifact.
• Created migration action item list for Plexis to keep track of developments across the SDLC.
• Analyzed eligibility data extracts, performed field analysis, resolved issues & performed data analysis for the projects.
• Assisted in provider communication on process changes in Plexis& TMG billing systems.
• Conducted data mapping of transactions from facets database & sourced procedure codes from data stores of facets claims.
• Configured the front-end claims processing in facets & developed workflows related to claims processing.
• Worked in claims processing system for pharmacy benefit management along with review, design & reconfigure of facets in functional areas like membership, claims, provider, enrollment & service.
• Worked on the EDI 834 file load to facets through Membership Maintenance sub system.
• Worked with facets team for HIPAA Claims validation & verification process (pre-adjudication).
• Work with training providers on moving to a new system in BCBSND through portal & changes on billing to TMG Health vs. BCBSND.
• Engaged with business units and stakeholders to define scope of effort, work deliverables, and project plans for data warehouse project which was due for migration to snowflake.
• Did Data restructuring to convert data into different formats& data editing to remove errors for further processing.
• Identified & documented complex data analysis, data mapping & error resolution for different transactions.
• Coordinated with Project Managers to resolve risk issues and ensure compliance of Security System related to the HIPAA.
• Worked with the system administration team, technical leads, & PM to release builds to production through EDI Gateway.
• Hands-on experience in the design, development, implementation, and production activities associated with X12 transaction sets (278 1 7, 834, 837, and 835), and other proprietary data standards.
• Did impact analysis, vendor analysis & GAP analysis for migration from ICD-9 to ICD-10.
• Created detailed ICD 9 & ICD-10 mapping and crosswalk analysis as per the client specifications.
• Performed Web Portal testing and Web Portal Post Implementation testing for 278,270/271,276/277,837PID.
• Gathered and documented ND State client business requirements and developed, entered and verified test cases.
• Created mapping documents and also updated Companion Guides for 278, 270/271,276/277,837I.
• Analyzed results and EDI ANSI X12 file mapping and reported on standard analysis spreadsheet.

Environment: EDIFECS, Facets 4.X, Oracle, QTP, Mainframe, SQL, MS Suite, IBM Rational Suite, UltraEdit, Rational Test Manager, HP QC, Unix, SCRUM/AGILE, JIRA.

Confidential, Southfield, MI

Sr. Business Analyst

Responsibilities:

• Worked on the PPACA for various mandates such as Grandfather Rule, Rescissions, D-26, Pre Ex-19, Preventive Care, Operating Rules, and Early Retirees Fund etc.
• Captured the list of all the tables from Member/Subscriber modules in FACETS and all the dependent and related tables from other modules such as Claims and Providers for data mapping.
• Conducted mapping of ICD9 to ICD10 as per GEMS/Custom-edits and analyzed existing systems to produce RFP’s using NetworXPricer.
• Involved in requirement gathering and database design and implementation of star-schema, dimensional data warehouse using JIRA.
• Develop SQL queries to extract data from Netezza and Snowflake in order to support business requests and perform ad hoc analysis.
• Responsible for gathering and documenting Legislative, Business, Functional requirements for all the provisions and their impact on the existing products and systems.
• Did create user-stories, prioritized product backlogs, developed sprint velocity reports, acceptance criteria etc. in SCRUM/AGILE
• Aligned resources of infrastructure, data warehouse, analytics, and operations to produce solutions.
• Used NetworXPricer to conduct claims processing & the networx payment bundling administrator to perform operational task
• Created storyboards, sprint burndown charts, monitoring details, developing processes, releases, reports etc. using JIRA.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Performed Requirement Analysis and developed Use Cases and Activity Diagrams using MS Visio.
• Traced High Level Requirements (HLR) to Detailed Level Requirements (DLR).
• I conducted meetings with SME's to understand current business process and performed Gap Analysis to meet future business needs.
• Performed data mapping of transactions from facets database & also sourced procedure codes via facets claims.
• Create daily, weekly, monthly and ad-hoc reports using SQL Server using data from our Facets system.
• Mapped EDI 4010 transactions: 837I/P/D, 270/271, 276/277 to HIPAA 5010 as per CMS Mandate & did GAP analysis
• Created and managed project templates, use case project templates, requirement types and traceability relationships in MKS Integrity.
• Worked as Oracle data warehousing administrator or designer- Configured an Oracle database for use as a data warehouse, designed data warehouses, Performed upgrades of the database and data warehousing software to new releasesManaging schema objects, such as tables, indexes, and materialized views, Managed users and security, developed routines used for the extraction, transformation, and loading (ETL) processes, created reports based on the data in the data warehouse, Backed up the data warehouse and performing recovery when necessary, Monitoring the data warehouse's performance and taking preventive or corrective action as required.
• Generate reports using Tableau and Excel, utilizing multiple data sources: Athena, Snowflake, SQL Server and OLAP Cubes .
• Wrote SQL Queries using TOAD to do data validation and verification for all projects
• Developed Systems Specifications document to define the impact of the new requirements on the existing system.
• Developed and managed creation of product documentation to communicate features, benefits, positioning and impacts to different audiences and ensured that documentation deliverables from various groups are produced as needed.
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 837 and proprietary format files and Reports development.
• Wrote test cases and test scripts for SIT/UAT

Environment: RequisitePro, Rational Rose, XML, ClearCase MS Office, MS-Visio, Facets, SQL, XML, Java, TOAD, Quality Center, MS Project, SOA, IBM Suite, HP Suite, HP QC, IBM Rational Test Manager, IBM Rational Clear Quest, JIRA, SCRUM/AGILE

Confidential, Des Moines, IA

Business System Analyst

Responsibilities:

• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
• Maintained and Migrated tables from the local database to on-premise cloud database Snowflake by creating ETL's .
• Captured Medicaid specific business requirements and developed BRD’s, functional specification document.
• Facilitated collection of Functional Requirements from system users, and prepared Business Requirement documents and have applied the RUP model throughout the entire development and testing process.
• Planned and staffed the project to redesign, develop, and deploy a new data warehouse.
• Compared and validated 5010 system test results with 4010 results for the same test scenarios using NetworX.
• Prepared Logical Process and Data Models that contained set of diagrams and supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the data elements to analyze and document Business Data Requirements.
• Worked in SCRUM/AGILE methodology extensively using JIRA to do story-boards, user-stories, velocity graphs, product backlog items, customizable workflows, roadmaps, filters etc.
• Worked on MITA for MMIS upgrade as per the client requirement.
• Worked with the Data stewards to identify and document business rules that need to be applied to the Care Management data in the warehouse
• Created SQL Queries using SQL Server to do data mapping and data analysis work as required by the client
• Did data mapping, cross-walk analysis and GAP analysis for the processes.
• Perform ETL of data into Snowflake from Oracle databases.
• Used Rational Clear Quest to maintain and track the requested enhancements and changes by the stakeholders.
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams.
• Worked closely with the offshore team to convey Technical and Functional specifications.
• Planned, coordinated analysis, design and extraction of encounter data from multiple source systems into the data warehouse relational database (Oracle) while ensuring data integrity.
• Worked on 837I/P/D and 835 transactions as well as devised process flows for Claims Processing System
• Detailed understanding of business functionality and preparing the Functionality Test Plan
• Interacted with Product Manager and Domain Experts to understand various process plans, business process, and functionality in detail.
• Create and run SQL via, Snowflake and sql developer, update data for ad hoc requests
• Responsible to conduct walkthrough sessions to get Business Sign off for the FRD.
• Meetings with Developers, Team Leads to help them understand the requirements.
• Interacted with the Testing and Development team to resolve and follow up on development issues.

Environment: MS Office Tools, Windows XP, MS Project, RequisitePro, Rational Rose, SQL, ClearCase, MS Powerpoint, MS-SharePoint, MS-Word, MS-Excel, Business Objects, XML, JIRA, SCRUM/AGILE.