SUMMARY:

• Over 6 years of experience working as Business Analyst in Healthcare domain.
• Specific expertise in Business Analysis, GAP Analysis, Data Analysis, and creating business process documents.
• Detailed knowledge of the Software Development Life Cycle (SDLC) phases.
• In depth knowledge and hands on experience working with SDLC methodologies like Waterfall, Scrum, and Agile.
• Expertise in preparing Business Requirement Documents, Use Case Specifications and Functional Specifications.
• Hands on experience of UML diagrams such as Use Case Diagrams, Activity Diagrams and Sequence Diagrams.
• Experience in using Joint Requirement Planning (JRP) and Joint Application Deployment (JAD) sessions for gathering requirements and brainstorm ideas.
• Hands on experience and understanding of healthcare industry standards and transactions such as EDI 820, 834, 835, and 837, Electronic Health Record (HER), Electronic Medical Record (EMR), HL7 codes and messages, and CCD (Continuity of Care Document).
• Well experienced with the complex tasks of ICD 9 to ICD 10 conversion and mapping.
• Strong understanding of EDI Claims, Member Enrollment, Eligibility, and HIPAA 5010 (X12) standards
• Knowledge of different modules within Healthcare Claims Adjudication Process ( process, billing process and enrollment & Claims process).
• Excellent experience various EDI files such as 837 Claims processing, 834 Benefit Enrollment, 820 Payments.
• Understanding of HIPAA EDI inbound and outbound transaction, and HIPAA conversion analysis.
• Extensive experience in full HIPAA compliance lifecycle from GAP analysis and migration of HIPAA ANSI X12 4010 to ANSI X12 5010 and translation of ICD - 9 codes into ICD-10 codes.
• Experience with HIPAA compliance in the Healthcare systems. Experience providing analysis for business processes running on EDI (Electronic Data Interchange) standard.
• Knowledge and experience working with FACETS 4.71 & 5.0 claims processing, dental claims, & dental claim pricing.
• Ability to supervise and make sure testing is done with regards to requirements of the project.
• Detailed understanding of batch jobs, ETL process, SSIS packages, and data migration during ETL. Hands on experience in writing SQL queries for data validation.
• Excellent project management skills and hands on experience working with software like Microsoft Project.
• Experience creating testing documents such Test Plan, Test Cases, Test Strategy
• Excellent working knowledge of requirement management tools like Microsoft SharePoint.
• Excellent presentation and communication skills, can act as an excellent mediator between business and technical teams. Experience with handling UAT.

TECHNICAL EXPERTISE:

Methodologies: Waterfall, Scrum, Agile, UML

Testing Tools: SOAP UI, QTP, JIRA, Requisite Pro, SharePoint, Quality Center (ALM)

PROFESSIONAL EXPERIENCE:

Confidential, KY

Sr. Business Analyst

Responsibilities:

• Analyzed the impacts of HIPPA 5010 project on enrollment, Claims and Benefit.
• Studied existing business application and processes, collected end user requirements and suggested the improvised business process model.
• Worked in a team of six in an offshore/onsite model.
• Worked with external teams and used knowledge of EMR for data validation & verification.
• Collaborated with various teams during HL7 v2.5.1 implementation. Wrote requirements for batch files and message formats for HL7. Validated Patient Code Sets, Vaccination Code Sets, and Miscellaneous Code Sets during HL7 implementation.
• Gathered, defined and documented highly complex business requirements for NPI crosswalk implementation.
• As part of validation process for EDI 820, outlined the discrepancies in eligibility reconciliation process and updated the process after discussion with stakeholders.
• Created mapping for EDI transactions, specially 820 and 834. Outlined the updated processes for Payment Reconciliation, Eligibility, and Premium Payment Transactions
• Worked on Dental Claim Detail Error Reports in Facets Reporting to identify claims that were not successfully moved to the Facets claim table.
• Updated process flows for implementation of various modules for Facets 5.0 including dental claim pricing, payment processing, & workflow management.
• Worked on functionalities such as Premium Payments, Enrollments and Claims.
• Responsible for documenting As-Is and To-Be systems.
• Migrated HIPAA ANSI X12 HIPAA 4010 to HIPAA 5010 transactions.
• Application integration with EDI-X12, EDI-820/834, Payment Reconciliation.
• Designed process flow for data archival, data purging, delta calculation during batch jobs to outline XML file triggers in Inbound & Outbound folders using transaction X12 EDI 820 and834.
• Performed Gap Analysis for HIPAA 5010 enhancement using TR3 implementation guides & side-by-side HIPAA (X12) guides provided by CMS (Center for Medicare & Medicaid Services).
• Review and understand the claims process and complex requirements for the enhancement of the current system created under the Requirement Specification Documents after conducting interviews with End Users, JAD Sessions and analyzed their current systems.
• Writing the General System Design Documents that demonstrate current and proposed/solution business design and changes to the current Legacy System.
• Performed data validation by writing SQL queries during ETL batch jobs.
• Documented complex Business requirements and made process flow diagram for the EDI transactions EDI 837, 835, 820, & 834 as per the implementation for Medicaid claim processing system enhancement.
• Worked on Data Mapping documents explaining flow of data from one-to-another table for the system enhancement purpose required by HIPAA 5010 implementation.
• Maintained Requirements Traceability Matrix (RTM) throughout the project.
• Developed Companion Guides for the business users.
• EDI file testing for checking the HIPAA 5010 (X12) compliance of the inbound 837 claims.
• Testing of outbound 820, 834, 278RESP EDI files.
• Worked on Impact Analysis of ICD-09 to ICD-10 on the current Legacy Systems.
• Worked on the GAP Analysis of PHASE I & PHASE II rules of AS-ECS (As Simplification Electronic Claims Status).
• Conducted User Acceptance Testing and User for the HIPAA 5010 Project.

Environment: Quality Center (ALM), SharePoint, File Viewer, MS Office, MS Visio, HIPAA X12 translator

Confidential, Bloomfield, CT

Business Analyst

Responsibilities:

• Worked with business users to understand the Eligibility Reconciliation and Payment Reconciliation process.
• Created and maintained data mapping document(s) in to the HIPAA mandated X12 format EDI transactions 820, 834, and 835. Performed GAP Analysis on (X12) transition
• Gathered business requirements, analyzed data sources, workflows by conducting interviews and meetings.
• Created business process models, flow diagrams, activity diagrams, use cases and wrote Business Requirement Documents (BRDs) and Functional Requirement Documents (FRDs) using tools and applications such as MS Word, MS Excel, and MS Visio.
• Worked on mapping various message types and Segments for HL7 validation. Validated various HL7 and User Defined Tables.
• Worked on CCD implementation guide for sharing Continuity of Care Record (CCR) patient summary data using the HL7 Version 3 Clinical Document Architecture (CDA). Outlined important information for stakeholders.
• Worked on Dental Claims process flows and error reporting.
• Validated CCD templates contained correct information in different Templates i.e. Header, Procedures, Family History, and Social History etc.
• Worked on Electronic Medical Record (EMR) files to verify comprehensive patient history was saved and displayed correctly.
• Used Rational Clear Quest as a workflow tool for effective change management and for testing management.
• Modified and redesigned the document for Plan Type Codes, Reason Codes, Relationship Codes, and Language Codes as part of Electronic Enrollment/Reconciliation process updates.
• Analyzed EDI 820 (Payments and Remittances) and 834 transaction (Enrollment and Maintenance) for the conversion of health insurance enrollment.
• Held JAD sessions to make sure all requirements were well understood by the team.
• Implemented the suggested changes and finalized the design to be presented to the developers.
• Designed Information Flows for Eligibility Reconciliation, Premium Payment Transactions, and Reconciliation of Enrollment Transactions EDI Processing to outline updated processes.
• Wrote SQL queries to gather data required for supporting the application development.
• Held meetings and constantly updated the BRD and FRD as per the changes requested by the stakeholders and approved by the Change Control Board (CCB).
• Actively conducted and participated in status report meetings and interacted with developers to discuss the technical issues.
• Wrote SQL queries for data validation during ETL process. Validated Error Log tables during SSIS package failures. Verified correct validation checks were performed when ETL jobs were triggered through SSIS packages.
• Modified the file format and layout for Electronic Enrollment & Reconciliation Payments.
• Actively participated throughout the User Acceptance Testing (UAT) process and helped coordinate the application deployment process.
• Worked independently with minimal supervision throughout the project.

Environment: Waterfall, MS Office, SQL Server 5.0, QTP, Quality Center, EDI 820/834/837/X12

Confidential, Virginia Beach, VA

Business Analyst

Responsibilities:

• Interacted with the stakeholders and end users in order to define the purpose and scope of application and gather User Requirements.
• Developed Process/workflow analysis by understanding the process modeling.
• Validated business requirements by facilitating JAD sessions.
• Designed and documented Business Requirements (BRD) by using ASCI ASX X12 EDI guides, reviewed and interviewed business process owners and companion guides.
• Analyzed and confirmed the source and target data in the database using Oracle SQL Developer. Updated Electronic Enrollment/Reconciliation Data Form.
• Created mapping for EDI transactions, specially 820 and 834. Outlined the updated processes for Payment Reconciliation, Eligibility, and Premium Payment Transactions.
• Prepared business requirement documents and functional requirements documents.
• Application integration with EDI-X12, EDI-820/834, Payment Reconciliation
• Facilitated meetings with users for requirement collection, design changes and feedbacks.
• Created and designed documents to outline the process to completely automate payments posting for Medicare, Medicaid and commercial payers electronic payments files.
• Followed UML based methods using MS Visio to develop use cases and activity diagrams; assisted developers in creating sequence diagrams and collaboration diagrams.
• Followed and implemented Agile methodology across multiple projects.
• Created and Maintained Test Matrix and Requirement Traceability Matrix.
• Worked with business partners and other groups to lead Quality strategies for projects and platforms
• Facilitated requirement review & update sessions with stakeholders to ensure all stakeholders are on boarded and approve the enhancements.
• Created process flow diagrams and data flow diagrams to show interaction of various systems and the data flowing through various systems.
• Created technical documentation, Reviews, analyzes, and evaluated business systems for end user needs, including Companion Guides, business process reengineering, including GAP analysis and documenting requirements, documenting processes, and workflows.
• Created Requirement Matrix, Process Flows, and Use Case Documents to support the implementation of Facets Billing and Claims Processing modules.
• Prepared user instructions and use cases to conduct User acceptance testing (UAT).
• Facilitated the requirement changes and fixes along with the release management team.
• Wrote SQL queries to validate and map data during ETL batch jobs. Validated that data coming from multiple sources was being transformed and loaded as per the business requirements.

Environment: Windows XP, MS Visio, SQL Server, MS Access, MS Project, HP QC, Doors, X12, EDI 820/834/837