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Sr. Healthcare Business Analyst Resume

La Jolla, CA


  • Over 7+ years of Experience as Business Analyst in Healthcare including understanding of Joint Application Business Requirement Gathering and business analysis.
  • Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
  • Knowledge and Experience on, Billing, Claims Payment Processing in relation to HIPAA, EDI 4010, 834, 837,835, and 270, 271.
  • In dept. knowledge of Software Development Life Cycle SDLC methodology such as Agilescrum, Waterfall and RUP.
  • Experienced in providing Medicare operations support, with a focus on leading configuration activities for Medicare Part D operations and also in Requirements Traceability Matrix (RTM) and test plan.
  • Efficient in writing Business Requirements Document, use cases, HIPAA, Use Case Specifications, Functional Specifications and Workflows.
  • Possess strong PBM (Pharma and claims system background) experience
  • Developed business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
  • Strong knowledge of Use Cases, MITA and Activity Diagram and profound knowledge of EDI X12 standards in healthcare insurance.
  • Involved in Facet Implementation and conversion of 4.21 and also in TriZetto Facets and TriZetto HIPAA Gateway 4.11.
  • Extensive detailed knowledge about clinical trials,drug development and drug discovery cycle
  • Extensive Experience in Functional, Integration, Regression, MMIS, HL7, FRD, User Acceptance UAT, MITA, System.
  • Strong Knowledge and experience of EDI transactions and HIPAA 5010 ASC X12 Transaction sets: 834 (Benefit Enrolment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820 (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response).
  • Proficient in Developing and executing Test Plans, Test Case, FRD, TriZetto Facets 4.x and Medical Billing, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
  • Excellent working knowledge in Project Life Cycle and clear understanding of Project Management.
  • Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end - state requirements.
  • Conducted successful projects with the help of teams to achieve deadlines timely and proficiently AND Worked on FACET claim processing system.
  • Strong knowledge of the Merit-based Incentive Payment System (MIPS) which is a system for value-based reimbursement under the Quality Payment Program (QPP).


Confidential, La Jolla, CA

Sr. Healthcare Business Analyst


  • Developed business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
  • Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility and billing essential.
  • Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
  • Managed company's EDI catalog for prospective EDI customers.
  • Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
  • Implemented new services and programs via MMIS for the Medicaid program by directly interfacing with the customer and the system engineers on a regular basis.
  • Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for both HL7 ADT interface and the application.
  • Developed a work plan that ensured RFP would meet federal prior approval requirements including use of modular project development, compliance with HIPAA and other federal guidelines
  • Created documentation such as BRDs and FSDs (Business and Functional design specs) with elaborate Use Cases and process flows
  • Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
  • Analyzed and documented Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
  • Participated in JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
  • Facilitated all Aspects of scrum framework, including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and sprint retrospectives.
  • Created data mappings to transform the data according to business rules.
  • Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
  • Prepared various diagrams by using MS Visio.
  • Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.
  • Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.
  • Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.

Confidential, Dallas, TX

Business System Analyst


  • Participated in project meetings to support the team as required, organized various meeting with SME's and testing Team to ensure that we are on track with all our deliverables, tracked all our deliverables daily by using Deliverables tracking Template.
  • Teamed up with both internal and external software development teams to provide functional requirements specifications in the form of use cases, business process flows, and prototypes and management reporting requirements.
  • Designed Data Flow Diagrams (DFD's), Entity Relationship Diagrams (ERD's), and web page mock ups using modelling tools. Involved in formatting data stores and generate UML diagrams of logical and physical data. Used Facets for various health insurance areas through EDI 837, such as enrolment, member, Products and other Facets related modules.
  • Networked with Subject Matter Experts, Project Manager, Developers, and Process Analysts to understand the business process, gathered Business Requirements and identified enhancements.
  • Extensively developed project documentation, process flow documents, formal proposals, RFQ's and RFP's. Formulated methodologies and developed SDLC phases, strategies, time & cost estimates with milestones for each phase.
  • Responsible for demonstrating requirement traceability within developed products.
  • Responsible for analyzing pending claims in dispute using Facets.
  • Prepared Business Requirement Documents (BRD's) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
  • Tested the Facets system through EDI transactions mainly on 837 Professional and Institutional Claims enrolment.
  • Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system.
  • Creation of a Mapping Document for ICD9 Codes to ICD 10 Clinical Modifications and Procedural Codes.
  • Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System

Confidential, OH

Business Systems Analyst/EDI Analyst


  • Developed the scope and vision documents that defined the primary goals, objectives and scope of the project.
  • Validated batches of medical claims data, patient details, and service line data in the EDI 837 and EDI 835 files, 270 (Eligibility) and 276 (Claim Status) data.
  • Gathered requirements and developed project scope for implementation.
  • Collaborated with colleagues providing knowledgeable insight to customers and business partners.
  • Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical Specifications.
  • Created and managed Impact Analysis Documents, Business Requirement Documents, Design and Solution Documents, Use Case Specifications and Requirement Traceability Matrices (RTM).
  • Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
  • Created project plans for customer master process development and testing.
  • Identified various business processes and developed process flow diagrams for the business processes and validated the same with SMEs.
  • Identified Requirements and grouped them into Business Requirements, non- functional Requirements and Functional Requirements.
  • Recommending effective methods for documentation based on the complexity of the project.
  • Prepared Use Case Diagrams and Use Case Documents.
  • Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
  • Involved in testing data mapping and conversion in a server based data warehouse.
  • Recommend tactic to implement HIPAA 4010 ( EDI X12 837,834,278,270) in the new System
  • Validated all the incoming/Outgoing data from EDI 837/835 interfaces.
  • Followed the RUP based methods using Rational Rose to create: Use Cases, Activity Diagrams / State Chart Diagrams, Sequence Diagrams.
  • Work with EDIFACT messages like ORDERS, ORDRSP, INVOIC, ORDCHG, and REMADV.
  • Developed and supported startup for MVS and PC based EDI systems and various application integrations and interfaces.
  • Drafted testing strategy for the claims Management Systems in accordance with HIPAA rules and regulations pertaining to PHI.
  • Validated all the incoming/Outgoing data from EDI 837/835 interfaces.
  • Converted various SQL statements into stored procedures thereby reducing the Number of database accesses (since Stored Procedures passes the whole block at one time.)
  • Developed Mapping rules, Design specifications and Use Cases for the HIPAA 837i/p/d; 270/271, 276/277, 835, 824, 275 and others. Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277).
  • Create EDI Transaction (invoice file) and EDIFACT
  • Documented various key elements of HIPAA compliance and made sure that they are understood complied and followed by the development team members.
  • Conduct manual Regression testing for the developed test cases on Biztalk environment.
  • Used COVAST EDI and HIPAA Accelerator for BizTalk 2006 R2.
  • Delivered solutions and closed problems in the Problem Queue assigned by running the tests in CLAREDI, HIPAADESK and other applicable Clearing Houses

Confidential, Morristown, NJ

Business Analyst


  • Facilitated interview, one on one and brainstorming sessions with SME's User's in understanding the requirements pertaining to billing Origination to billing Processing.
  • Responsible for providing Medicare Operations support, with a focus on leading configuration activities for Medicare Part D operations.
  • Extensive knowledge of Medical Management Information Systems (MMIS) and HL7.
  • Assisted and written System Requirements Documents SRD, including Functional and Non-Functional requirements.
  • Reporting issues into the Facet system and Develop FRD's, FDD's and Use Cases (MS Visio), process flows for the project and decks.
  • Delivered business requirement documents, functional specification documents, Use Cases, test plans, and requirement traceability matrices.
  • Profound knowledge of EDI X12 standards in healthcare insurance
  • Verified accuracy of billing information and codes before processing Medicare and Medicaid forms, as well as other third-party insurances.
  • Gathered business requirements through interviews, surveys, prototyping and observing from account managers, finance manager, and independent advisors and got an accurate understanding of their needs.
  • Developed Use cases and activity diagrams and analyzed business requirements and Working skills on Health Level 7 Interface (HL7).
  • Created UML-based feasibility studies and Use Case Models to communicate those ideas to the developers.
  • Followed the UML based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, and Sequence Diagrams.
  • Worked with SME's and business users to gain in-depth understanding of the business' mission, objectives, purpose and processes.
  • Responsible for sales and marketing specializing in practice management, managed care systems, thin-client technology, Electronic Media Records EMR/EHR/PHE/PMR, ASP technology, and full integration tools.
  • Enhanced the business to articulate and prioritize their ideas and assisted in development of materials for new technology and process improvements.
  • Collaborated with the QA testing team to develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
  • Conduct project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.
  • Involved in the User Acceptance testing UAT to check the reliability for end users.

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