SUMMARY:

• Total over 10+ years of IT experience, with 8 + years’ experience as a Business Analyst using the software development lifecycle principles to manage Business analysis, business re - engineering, requirement gathering/analysis, Pharma experience with Regulations and change control reviews.
• Highly experienced in both Agile and Waterfall methodologies.
• Industries worked in include health, insurance sector (especially Facets-claim processing tool).
• Familiarity with current healthcare industry standards such as CMS and MMA Guidelines, HIPPA guidelines.
• Highly proficient in working with users to gather requirements, analyze them and subsequently use Rational Product and design tools to document the requirements.
• In-depth knowledge of creating use cases, activity, logical, component and deployment views to extract business process flows and workflows.
• Experience working as Facets Benefits/Pricing Configuration Analyst, Benefit Implementation Specialist, Research Specialist, Coding Specialist, FISS System Specialist, Reimbursement Analyst, Health Rules/HealthEdge.
• Used Tableau extensively for reporting and data analysis.
• Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid.
• Expertise in validating the companion guides on various EDI transactions.
• Proficiency in Defect management, including Defect creation, modification, tracking, and reporting using Industry standard Tools like HP Quality Center/ALM, Clear Quest, TFS - Team Foundation Server.
• Ability to create business and functional specifications for data warehousing/ BI projects according to business needs and to coordinate with technical team for any clarifications.
• Extensively used Rational tools for creating use cases, version control, and defect tracking & reporting and applied the Rational Unified Process in all areas of the Software Development Life Cycle.
• Worked with technical teams (in-house and off shore) to develop the solution and get user acceptance, through excellent communication and detailed documentation skills.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277).
• Requirement Analysis, Use Case development, and UML Modeling using Visio.
• Experienced in RUP, Agile, Water fall Methodologies and in conducting Joint Application Development/Design (JAD) sessions.
• Experienced with Requirements Gathering, Data Modeling, Data Flow Diagrams (DFD) and Flowcharts, System Architecture, Feasibility studies, Scope Documents & Requests for Proposals (RFP).
• Strong Knowledge/familiarity with data projects, ETL processes, databases, data warehouse, and reporting concepts and Healthcare experience in managing Project.

TECHNICAL SKILLS:

Methodologies: UML, Waterfall, RUP, Agile/Scrum, OOAD

Requirement Management Tool: Rational Requisite Pro, SharePoint, Caliber, Documentum, DOORS

Testing and defect tracking Tools: Rational Clear Quest, Rational Clear Case, Quality Center, ALM, TFS

FrontEnd Tools: Microsoft Front Page, MS Office, MS Project, MS Visio

Project Management: Oracle Primavera P6

Web Development: HTML, XML

Programming Languages: PL/SQL, SPSS, SAS

Data Bases: Informatica, Erwin data modeler, DAISE( Confidential s in build ), Oracle 10g, Microsoft Access, MS SQL Server 2005

Business Intelligence (BI): Cognos, Tableau

Operating Systems: Windows NT/2000/XP/9x, DOS, UNIX,LINUX

EXPERIENCE:

Confidential, Durham, NC

Sr. Business System Analyst

Responsibilities:

• Created and maintained FSD’s ( Functional Specification Document) and assist in TDD ( Technical Design Document) and assisted PM while managing multiple projects
• Converted Business Requirements to the Functional Specification for Facets Optimization Projects (multiple business service requests).
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams thus defining the Data Process Model and Business Process Mode
• Prepared logical Data Models that contains set of diagrams and BRDs (Business Requirement Documents) supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze and document business data requirements from Data ware house
• Created various database objects like views, tables, and procedures to extract data and support the end user reporting data ware house requirements.
• Performed Optimization of Facets tool by automated Premium entry into Facets. Captured correct premium price. Auto Flag all external COB (Co-ordination of Benefits) automatically.
• Involved in Validation of HIPAA/EDI for 270/271, 276/277, 837, 837i and 835 claims used for professional, Institutional and Dental billings by Writing Test cases, Test Plans
• Worked on Optimization of Facets to detect the correct site of care of patients in Facets. Location was not detected in Facets, it was fixed.
• Worked on Optimization of Facets, by fixing voice of customers, where premium was increased due to multiple reasons but reason was not detected properly and explained to member on invoice or warning message. Reason was not properly tracked in audit trail of Facets also.
• Worked on Optimization of Facets where patients HIC numbers were changed by MBI (member Identification number), as HIC number (which shows SSN # of patient too) was exposed to provider on Blue-E side from Facets to Blue-E.
• Conduct JAD sessions to gather and document requirements that enhance a wide range of functionalities including claims processing, eligibility and enrollment, provider networks, and electronic data interchange for our Facets core application.
• Migrating the claims processing process from Mainframe to Microsoft base process using HealthEdge package Responsibilities.
• Experience in configuration of claims adjudication systems, i.e., FACETS & MMIS. Experience with ITS systems involved in Blue Square applications.
• Worked on migration of Large Group 50+ from pMHS legacy system into Facets by completing FSD (technical specification or Functional specification document)
• Involved in sprint planning sessions to identify the features and functionalities that should be achieved by the new application. Identified various points of integration among the new and existing applications and required integration with other IT components.
• Involved in creating documents and draft UML Diagrams using MS Visio for Enrollment according to the HIPAA 834 Compliance Standards for Enrollment.
• Analyzed the Application to scope out errors after submittal of transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Worked on EDI Health Care Claim Payment/Advice Transaction Set (835)

Environment: Facets, SQL developer, Selenium, Business Intelligence (BI)-OBIEE, Crystal Reports, Oracle.

Confidential, Hartford, CT

Sr. Business System Analyst

Responsibilities:

• Prepared requirements documents and assisted lead BA in efforts to prepare documents for ongoing requirements gathering efforts along with other team BAs.
• Participated in discussions with technical team to clarify existing business processes and identify opportunities for improvements. Translated business processes to flow diagrams.
• Worked in Software development life cycle (SDLC) using Agile Scrum methodology.
• Conducted ongoing Employer Profile Maintenance (EPM) requirements gathering sessions by Interacting with Business team, Subject Matte Experts (SME’s) and IT team.
• Helped other BAs onboard as new state staff analyst.
• Experience in managing stakeholders from multiple teams and tracking activities
• Worked on Clear Case, Visio Process Flows, developed Business Rules Documents, Business Requirement Documents (BRD), Task Specifications Documents, and Use Cases.
• Created transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271,835, 837-(I, P, & D), 835, 834, 820.
• Tested Schemas of EDI ANSI X12 Claims (837-HealthCare Claim and 267-Individual life, Annuity and Disability Application) and Eligibility forms in XML.
• Discussed all documents with Subject Matter Experts (SMEs) on SharePoint in requirement sessions, Joint Application Development JAD sessions (for brainstorming), root cause analysis and approval sessions were done. Involved in HIPAA assessment and HIPAA X12 EDI transaction mappingfor X12 267 with long-term disability (LTD) and short-term disability (STD).
• Used Tableau extensively for reporting, BI Business Intelligence and data analysis.
• Act as a support to Project Manager, worked on Project definition by documenting high level Project Scope and Timeline. Obtain Project Sponsor’s approval and sign-off for the Project Definition. Identified Project Stakeholders, their Roles and Responsibilities in project initiation stage.
• As a support to Project Manager-created Project Plan by creating task list and work breakdown structure (WBS).Indent or out dent tasks to finalize the WBS. Entered task durations or work estimates. Created dependencies between tasks and assigned resources.
• Wrote complex SQL queries like Joins, Update, Stored Procedures, Indexes, Reports, ETL packages to understand the low-level requirements.
• Analyzed User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT), and regression testing of unemployment Insurance registration domain. Experience of working through complete SDLC process of registration domain of unemployment insurance.
• In-depth exposure to System Development Life Cycle (SDLC) on each project phase.

Environment: Oracle, SQL, Rations suites, ProvidePortal, TeraData, HomeBridge, Business Intelligence (BI)-OBIEE

Confidential, Durham, NC

Sr. Business System Analyst

Responsibilities:

• Helped to communicate business priorities to the organization to effect business solutions
• Created and maintained BRD to assist PM close basis while managing multiple projects
• Converted Business Requirements to the Functional Specification
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams thus defining the Data Process Model and Business Process Mode
• Prepared logical Data Models that contains set of diagrams and BRDs (Business Requirement Documents) supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze and document business data requirements from Data ware house
• Created various database objects like views, tables, and procedures to extract data and support the end user reporting data ware house requirements.
• Involved in Validation of HIPAA/EDI for 270/271, 276/277, 837, 837i and 835 claims used for professional, Institutional and Dental billings by Writing Test cases, Test Plans
• Conduct JAD sessions to gather and document requirements that enhance a wide range of functionalities including claims processing, eligibility and enrollment, provider networks, and electronic data interchange for our Facets core application.
• Instructional Designer for AmeriHealth Administrators -Designing materials for new proprietary software - HealthEdge.
• Expert in eliciting requirements from Business users, Business owners, enrollment and billing Technician, and analyzed new requirements, and business rules for Facets System User Interface (UI). CareFirst BlueCross BlueShield housed their various products and data in Facets data tables in the Facets backend database.
• Gathered requirements and developed Process Flow diagrams in accordance with CareFirst and Medicaid business rules and regulations pertaining to the Facets configuration and evaluated the impacts of proposed changes.
• Migrating the claims processing process from Mainframe to Microsoft base process using HealthEdge package Responsibilities.
• Experience in configuration of claims adjudication systems, i.e., FACETS & MMIS. Experience with ITS systems involved in Blue Square applications.
• Involved in sprint planning sessions to identify the features and functionalities that should be achieved by the new application. Identified various points of integration among the new and existing applications and required integration with other IT components.
• Involved in creating documents and draft UML Diagrams using MS Visio for Enrollment according to the HIPAA 834 Compliance Standards for Enrollment.
• Analyzed the Application to scope out errors after submittal of transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Created and provided Ad hoc data request to the users with quick time around.
• Assisted other team member extract data from the data ware house and any data related issues.
• Converted business requirements into functional requirements.
• Worked on EDI Health Care Claim Payment/Advice Transaction Set (835)
• Set claims processing data for different FACETS Module.
• Involved in making Use Case Diagrams, Activity Diagrams, and using analysis and design models tools like MS Visio, Rational Rose through Agile and Waterfall Model.
• Validated EDI Claim Process according to HIPAA compliance.

Environment: Facets, SQL developer, Selenium, Business Intelligence (BI)-OBIEE, Crystal Reports, Oracle.

Confidential, Woonsocket, RI

Sr. Business Analyst /Data Analyst

Responsibilities:

• Worked on Confidential ’s data warehouse projects- RxDW and RxConnect as Confidential ’s Internal Pharmacy retail tool. Worked on Business Requirements (BR) doc’s on fast SDLC approved projects, Requirements Traceability Matrix (RTM) updates and Solution Requirements (SRP).
• Performed Pharma Regulations data profiling exercises for new and existing data areas.
• Developed detailed BRDs and FSDs using various modeling tools and developed databases based on the system model following the techniques in Agile.
• Performed high level data extraction and manipulation from various healthcare databases and files to support organizational quality, utilization initiatives and other information needs.
• Strong knowledge of data modeling principles and development best practices, plus Business Intelligence (BI) analysis experience.
• Filtered and "cleaned" data; reviewed reports, printouts and performance indicators to locate and correct code problems
• Conducted gap analysis to support business/system migration to Healthedge.
• Performed business analysis, data analysis and translate business requirements into data/technical specifications.
• Knowledgeable in traditional data warehouse concepts, including Kimball methodologies.
• Created and maintained Data Warehouse data model following set standards, utilizing both Relational and Dimensional Modeling techniques.
• Wrote Test cases and Defect report generation using TFS (Team Foundation Server).
• Assisted in designing conceptual and/or logical data models.
• Developed SQL queries, reports, and dashboards as needed for Business Intelligence (BI) team.
• Gathered, documents, and communicates requirements effectively to ensure appropriate implementation of business intelligence and reporting solutions.
• Analyzed and documented the flow of information between applications, databases, and third party (vendors) systems for data and reporting
• Prepared test cases and perform functional, acceptance, and regression testing
• Prepared ad hoc and regularly scheduled reports, and did analysis on extracted reports, maintained sales tracking system, referral reporting in Business Intelligence (BI) sub project.
• Used Tableau extensively for reporting, BI Business Intelligence and data analysis.

Environment: SQL developer, Toad, Business Intelligence (BI)-Tableau, TFS, OBIEE, Crystal Reports, Scrum, Oracle.

Confidential, Hartford, CT

Sr. Business System Analyst

Responsibilities:

• Worked on Confidential ’s internal tool on member domain of Member Payment Estimator (MPE) for new enhancements and up gradation, using Agile/Scrum methodology.
• Performed daily scrum meetings and evaluated the status of the agile team.
• Tracked the requirements and extended business needs (EBN’s) using rational tools in the agile environment.
• Managed the project risks and co-ordinate with the project manager about the agile project on regular basis.
• Demonstrated the agile/scrum project deliverables on regular intervals to the stakeholders and the whole team.
• Worked on the work break down structure of the agile/scrum project as a Scrum Master and assigned the tasks to the whole team.
• Performed Data Mapping to map the EDI 834 data to XML.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities.
• Identified the requirements for accommodating HIPAA standards for 837P transactions and captured these requirements to develop new GUI for the internet based application
• Set claim processing data for different Facets Module.
• Involved HIPAA regulations in Facets HIPAA privacy module.
• Created ANSI test files for the 837 (for Medicare Part A and B), 834 and 820 Transaction Sets.
• Developed Data Mapping and Crosswalk documents.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Troubleshoot any problems found within FACETS and when testing the SQL data database while validating the business rule.
• Involved in Confidential Implementation, involved end-to-end testing of HealthEdge Billing, Enrollment Claim Processing and Subscriber/Member module.
• Involved in creating test plan, test cases and test scripts using TFS for Functional and Integration testing.
• Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
• Expertise on Eligibility and Enrollment Member Management Project.
• Participated in developing and implementing End-End testing.
• Used TFS to write the Test plan, Test Cases and raise the Defects and to see the status and progress of every Test and projects.
• Wrote SQL queries for validating data. Any broken SQL query would be tuned using a data cleaning/ data scrubbing techniques.
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Extensively used SQL statements to query the Oracle Database for Data Validation and Data Integrity.
• Worked with the Provider data comparison and Pharma Regulation Publishing project too in provider domain and used automation tools (likeStrenuus Network 360 for reporting) to cater the needs of the provider team and it’s downstream.
• Used Tableau extensively for reporting and data analysis.
• These reporting tools, mentioned in above point, were used to help provider domain managers to update data in provider database.
• Generated various comparison reports at multi county level of provider’s data for data validation at audit level.
• Medicare data analysis at county level was also done, along with comparison of Confidential ’s data with multiple providers of other counties.

Environment: Oracle, SQL, Rations suites, Business Intelligence (BI) OBII, Strenus Network 360, TFS, Crystal Reports, Scrum/Agile.

Confidential, Burlington, MA

Sr.Business Analyst

Responsibilities:

• Prepared requirements documents and assisted lead BA in efforts to prepare documents for ongoing requirements gathering efforts along with other team BAs.
• Participated in discussions with technical team to clarify existing business processes and identify opportunities for improvements. Translated business processes to flow diagrams.
• Worked in Software development life cycle (SDLC) using Agile Scrum methodology.
• Conducted ongoing Employer Profile Maintenance (EPM) requirements gathering sessions by Interacting with Business team, Subject Matte Experts (SME’s) and IT team.
• Helped other BAs onboard as new state staff analyst.
• Experience in managing stakeholders from multiple teams and tracking activities
• Worked on Clear Case, Visio Process Flows, developed Business Rules Documents, Business Requirement Documents (BRD), Task Specifications Documents, and Use Cases.
• Created transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271,835, 837-(I, P, & D), 835, 834, 820.
• Tested Schemas of EDI ANSI X12 Claims (837-HealthCare Claim and 267-Individual life, Annuity and Disability Application) and Eligibility forms in XML.
• Discussed all documents with Subject Matter Experts (SMEs) on SharePoint in requirement sessions, Joint Application Development JAD sessions (for brainstorming), root cause analysis and approval sessions were done. Involved in HIPAA assessment and HIPAA X12 EDI transaction mappingfor X12 267 with long-term disability (LTD) and short-term disability (STD).
• Used Tableau extensively for reporting, BI Business Intelligence and data analysis.
• Act as a support to Project Manager, worked on Project definition by documenting high level Project Scope and Timeline. Obtain Project Sponsor’s approval and sign-off for the Project Definition. Identified Project Stakeholders, their Roles and Responsibilities in project initiation stage.
• As a support to Project Manager-created Project Plan by creating task list and work breakdown structure (WBS).Indent or out dent tasks to finalize the WBS. Entered task durations or work estimates. Created dependencies between tasks and assigned resources.
• Wrote complex SQL queries like Joins, Update, Stored Procedures, Indexes, Reports, ETL packages to understand the low-level requirements.
• Analyzed User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT), and regression testing of unemployment Insurance registration domain. Experience of working through complete SDLC process of registration domain of unemployment insurance.
• In-depth exposure to System Development Life Cycle (SDLC) on each project phase.

Environment: Oracle, SQL, Rations suites, Business Intelligence (BI) OBII, Crystal Reports. Scrum/Agile.

Confidential, Cranston, RI

Sr. Business Analyst

Responsibilities:

• Worked on Requirement gathering sessions with RI client for Unemployment Insurance (UI) claims processing.
• Involved in all phases of Software development life cycle (SDLC) using Agile Scrum methodology.
• Once daily requirements session was done, on daily basis Minutes Of Meeting (MOM) of requirement sessions were refined in Clear Quest along with logging of GAPS and open items related to that session were entered. Later on previously entered open items and GAPS were tracked to change their status in case they are resolved or need further discussion.
• Documentation was done with detailed requirements on Rational Requite Pro (Req. Pro).
• On daily basis, client Meeting of Minutes (MOM) were written and updated in Clear Quest. Open action items were created and also verified in Clear Quest. Client meeting session topics were clarified through MS remote team on phone, with all doubts and root cause analysis, all previous documents related to in hand discussion were gathered from MS shared server. Gaps were logged daily and open items were attached in Clear Quest.
• Requirement templates were created and was done in Requite Pro for Correspondences, Reports &System Use Cases ( was added for business rules where applicable in system use case documents in Req. Pro).
• Description, Parameter list, Attribute sheet, Generation Logic, internal template, Pre and Post conditions were prepared for the documents while doing documentation.
• Requirement Sessions were completed for Benefits part which further included sections as Claims Intake, Monetary, Weekly Cert. (i.e. weekly ) Non-Monetary and Appeals. Calculations were performed in monetary sub- section of UI claims processing.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT) and regressiontesting of Unemployment Insurance sub part monetary and non-monetary section of benefits domain. Exposure to SDLC process of benefits domain for monetary & non-monetary sub domain.
• Requirements were gathered for topics like Federal Emergency Unemployment (EUC) and State Extended Benefits (EB),Trade Adjustment Act (TRA), Military (UCX) and Federal (UCFE) claims, Returning to work, TeleServe/payments, and Disaster Unemployment Assistance (DUA). Calculations of WBA and MBA were done. Combined claim wages (CWC) IB4 outgoing is send to Transferring state, which send back IB14 ( i.e. Missing wages or Incorrect wages) and claim is concerned then for reconsideration, once reconsideration is done, re-determinations is done on regular base period or on alternate base period in RI if not eligible on regular base period. Once redetermination of WBA and MBA is done for claim, decision is send back to claimant; claimant can appeal that adjudication decision back.

Environment: MS Office Suite, Business Modeler, Rational (ClearCase, Clear Quest, Req Pro), UML, DB2, Java, Visio, MS( SharePoint, Access, Project, Outlook, Visio), UML, Windows.

Confidential, New York, NY

Business Analyst

Responsibilities:

• Worked with Medicaid Reimbursement Program (MRT) for homeless individuals and SSI infants (i.e. infants with low weight and underline disease) for gathering business requirements, including functional and non-functional requirements. Handled JAD sessions and root cause analysis for IT department .Documents were prepared as BRD, SRD, FRD and technical specifications.
• Worked on Business Process decomposition to create hierarchy of processes in form of process work flow diagrams using Visio.
• Experience in data integration involving ERP/CRM (SAP/Veeva/SFDC/Concur).
• Worked with Medicaid Long Term Care (MLTC) project team reporting meeting minutes and action items in daily status meeting for project modules. Shared and managed information on SharePoint and Project Portfolio Management (PPM) web portal tool for IT department.
• Worked on Medicaid State Transportation Reimbursement System Access 2000 database through queries, tables, forms and reports by importing, appending, updating staff data and EC file. Created tables before updating EC file to maintain and update Medicaid Transportation Ledgers on weekly basis needed to pay provider claims.
• Developed process flows in MS Visio, including ID card generation process and Restricted Recipient Program (RRP) Work Flow Diagrams, using Swim Lane Diagram approach.
• Major work performed around Pharmacy claim table (Rx Claim table) in Pharmacy Management Claim Adjudication System.
• Complex History analyzed in Pharmacy domain through Dispense Date. Data cut of date checked and analyzed in monthly (IWH) and daily views (IWH D). Adjustments to complex history checked in every load month on each monthly load.
• Wrote and executed SQL queries to verify data in the reporting system.
• Data Warehouse Pharmacy Member ID of each record analyzed and mapped back to cumb id no (field) assigned by data migrator feeding from Pharmacy claim information.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT)and regression testing of Emblem’s Medicaid Long Term Care module under Medicaid Reimbursement Program. Gone through whole SDLC process of Medicaid Reimbursement Program (MRT) for homeless individuals and SSI infants.
• Worked in supporting production and post Go Live support of Medicaid Reimbursement Program (MRT) Confidential project. Worked with cross solutions tech leads and managed the production support by analyzing the technical issues, prioritizing, and triaging the production support tickets of Medicaid Long Term Care (MLTC) and State Transportation Reimbursement System.

Environment: MS Office Suite, MS Access, Oracle, UML, SQL Server, SQL, PL/SQL, Windows.

Confidential, Hartford, CT

Business Analyst

Responsibilities:

• Multiple Projects and Service requests were assigned. One of the Pharmacy project assigned was for creating the drug claims processing system and work on different modules like provider enrollment, member enrollment and coverage.
• Other part of Pharmacy project was to provide 50MDP discount for particular drugs which involves the new fields from source system and generating new tables into Enterprise Data ware house and their effects on downstream applications plus Business Intelligence (BI) analysis.
• Another project assigned was for indicator for the incoming claims effecting transactions 277, 820 and 834 (X12 transaction containing enrollment information such as member name, contact information, coverage information, etc.).Indicator field (electronic standard code) was added and moved to the enterprise data warehouse to be stored on the claim line table.
• Tested Schemas of EDI ANSI X12 Claims (835-Payment and Remittance advice, 276/277-Claim status request and response, 270/271-Eligibility Inquiry) and Eligibility forms in XML.
• Service Requests (SR) was assigned which are extensions of the main projects as a result of any major change in the business requirements. One of the Service Request was to work on Member Eligibility table and Group Eligibility Program table to change to logic on back related to Behavioral Health Case Management (BHCM) and Medical Case Management (MCM) indicators.
• Facilitate meetings with Confidential 's internal and business team for ongoing business analysis and to communicate multiple projects status to respective project managers.
• Responsible for Projects on 4010 and 5010 translation by adding indicator and Pharma domain for 50MDP discount on Medicare drugs for Low Income Cost &Subsity (LICS) group.
• Analyzed workflow process to derive requirements for existing system enhancements and Business Process Modeling (BPM) efforts using WebSphere Business Modeler in Business Intelligence (BI) analysis.
• Worked on Logical Data Model (LDM) designed by DBA to gather and match new fields and respective data types with source file from Architecture team and made simple to complex translation rules (psedo code with if else statements) in costume-build technical specification tool, DAISE for developers and Cognos for Business Intelligence (BI) team.
• JAD sessions were done with business and business requirements were gathered before working on requirements document as an analyst from Enterprise data warehouse team for Healthcare Claim processing.
• Work Product Inspection (WPI) first by team lead and then Work Product Review (WPR) by whole team including key business team were part of responsibilities to be performed after every requirements document, translation rules report (using Confidential 's Enterprise Data ware(EDW)house's inbuilt tool-DAISE).
• Worked closely with SQL Developers to generate report for cross functional team.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT), and regression testing of Confidential member eligibility system. Analyzed Claim Data and checked the Data Quality Report to determine if there is any Data Issues.

Environment: MS Office Suite, Rational RequisitePro, Rational ClearCase, Rational Clear Quest, ERwin, UML, SQL Server, Oracle, DB2, UNIX.

Confidential, Albany, NY

Clinical Quality/Business Analyst

Responsibilities:

• Liaison between internal and external business community of CLIMS Remote Order Entry (ROE) project and ECLRS Outbreak Management System.
• Applied guidelines for decomposing claim processing business functions and processes.
• Worked with SQL queries and joined clinical lab tables on DB2 using test environment on Clinical Lab Management Information Systems (CLIMS) database.
• Performed BA production check out using SQL queries and commands on DB2, along with data on Look Up tables for all projects in-hand before respective projects releases.
• Analyzed Claim Data and checked Data Quality Report to determine data issues.
• Completed documentation of claim scenarios for source system.
• Facilitated meetings with internal and external groups and communicated project status to upper management. Conducted user interviews, GAP Analysis, root cause analysis, facilitated JAD sessions related to lab configurations for multiple clinical labs, created agendas and documented analysis in requirements gathering for both CLIMS ROE and ECLRS project.
• Identified, researched, investigated, analyzed, defined and documented business processes and Use Case scenarios.
• Documented user requirements into Functional Requirements Documents(FRD) and Non-Functional Requirements Document (N-FRD) for development team to better understand application requirements and managed changes to specifications. Active role in project SDLC process.
• Created Data Flow Diagrams (DFDs), Entity Relationship (ER) Diagrams for database modeling and web-page mock-ups using MS Visio for acceptance from analysts, surveyors and stakeholders.
• Generated reports using Crystal Reports.
• Used Rational Clear Quest for defect tracking and managed defect assignment reminders to team.
• Created Work Flow Diagrams to explain business user about new system functionalities using ErwinData Modeler and took sign-off from management.
• Demonstrated good expertise in triaging, analyzing the technical issues and prioritizing the tickets in production support environment related to Remote Order Entry (ROI) of CLIMS.
• Used Rational Unified Process (RUP) Framework in combination with Model Driven Systems Development (MDSD) reducing risk for development of Medical Labs SOA components.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT), regression testing, end-to-end testing and user pertaining to old and new CLIMS ROE and test catalog (new CLIMS module). Build the whole project by going through SDLC process and finally completing the Remote Order Entry (ROI) guide for CLIMS by configuring the whole clinical labs.
• Provided Testing services in support of the CLIMS and related systems supporting the DOL Services including Interfaces to other clinical lab systems and ICD 9, related testing.
• Contributed to compliance analysis of HCR-HealthCare Reform and its role in Medicaid claims processing through EMEVS (NYS Electronic Medicaid Eligibility Verification System), HIPAA compliant ePACES (Electronic Provider Assisted Claim Entry System) and NYS Medicaid and Medicare Intermediary.

Environment: Rational Clear Quest, MS Office Suite, Erwin, MS Project, Java, ErwinDataModeler, PowerBuilder, SQL, Windows, Citrix Server, UML, Test Director.