SUMMARY:

• Over 6+ years of experience as a Systems Analyst/Business Analyst in Healthcare and Telecom Industry.
• Health Insurance Background - Specifically related to collecting requirements, documenting and representing the business, Use Cases, Business process improvements, etc.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• 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)
• Extensive experience with the SAS programming and in data step and with various SAS Procedures in Base SAS and SAS/Stat, including thorough knowledge of SAS Macro.
• Package Software: Expertise in Informatica ETL and reporting tools. Deep understanding of the Data Warehousing SDLC and architecture of ETL, reporting and BI tools.
• Expert in developing Business and System Requirements, Design Documents, working with requirements traceability matrix
• Experience in writing Request for Proposals (RFP), Statement of Work (SOW) and Standard Operating Procedures (SOP).
• Worked extensively on Business Requirements Elicitation, Issue List monitoring, Process Modeling, Gap analysis, Risk analysis, SWOT analysis and development of Functional Specifications.
• Extensive Knowledge about all the phases of Business Analysis Life cycle like Requirements Elicitation, Requirements Analysis, Requirements Documentation and Requirements Management.
• Very good at writing documents like Business Cases, Vision and Scope Documents, Statements of Purpose and Requests for Proposals.
• Data Warehousing experience using Informatica PowerCenter 8.6/8.4/7.1.4. Excellent skills in implementing ETL Packages using DTS and SSIS 2008/ 2005.
• Drawing on Experience in all aspects of analytics/data warehousing solutions (Database issues, Data modeling, Data mapping, ETL Development, metadata management, data migration and reporting solutions) I have been key in delivering innovative database /data warehousing solutions to the Retail, Pharma and Finance Industries.
• Have in-depth knowledge of Software Development Life Cycle (SDLC) methodologies, assisting and working as Scrum Master on several projects, vast experience working in Agile, Waterfall, RUP methodologies. Primarily in Agile methodology. Handling Scrum team offshore and onsite.
• Extensive experience in writing Use Cases and UML diagrams.
• Good understanding of Software Development Methodology including RUP and Agile methodologies. Facilitated many JAD sessions and Brain Storming sessions.
• Experienced in White Box/ Black Box Testing, User Acceptance Testing (UAT), Unit, Integration, Functional and Load testing.
• Assisted QA team in developing Test Scripts, Test Cases and Test Plans for the User Acceptance testing.
• Strong in developing test plans, test strategies, test cases, test data, test checklists, defect tracking & reporting, preparing test summary reports and conducting status meetings.
• Ability to multi-task and work smoothly even under extreme pressure. Experienced in creating and enhancing Test Scripts in Win Runner, QTP.
• Excellent experience managing the whole testing process using Mercury Interactive Test Management tool Mercury Quality Center.

TECHNICAL SKILLS:

Programming Languages: C, C++, HTML, XML, and SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite (Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Performance Testing Tools: Virtual User Generator, Load Runner

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

PROFESSIONAL EXPERIENCE:

Confidential, Washington, DC

Sr. Business Analyst

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Major experience in Insurance suite product(s) like Guidewire, Insurity and with other proprietary insurance applications. Working as a Guidewire Business Analyst for implementation of Guidewire Claim Center and Policy Center for Personal Lines Auto, Home and Umbrella/Liability Plus lines of Business.
• Involved in Guidewire Corporate Training on Guidewire Policy Center, Worked on Commercial Lines Property and Casualty Insurance.
• Consulted with healthcare third-party Administrator Company to develop conversion specifications for member, enrollment, and authorizations.
• Effectively manage EHR staff by hiring, developing, training, and overseeing personnel to meet the needs of the practice.
• Customized reports in JIRA for different teams to represent agile board project statuses and key metrics
• Built and maintained close relationship with all payer provider representatives to insure proper claims processing.
• Subject matter expert regarding Medicare regulations and operational procedures.
• 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.
• Experience in commercial Property and Casualty, Commercial Lines and Personal Lines Insurance, Underwriting, Rating and Guidewire experience with national carriers.
• Technically competent in Workers Compensation Case Management including complex claims, disputes, Regulatory matters, common law and litigated claims.
• Utilized the guidelines and artifacts of the Agile Methodology to develop a detailed implementation process Guidewire Claim Center Integration during different iterations and phases in Software Development Life Cycle (SDLC)
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Extensive skill on Guidewire Billing Center, Policy Center and Claims Center integrations.
• Aided the Product Owner for developing project plan as well as managing the project scope for the billing and policy center tool of the business insurance policies segment of property and casualty insurance.
• As a functional consultant, implemented Guidewire Policy Center through an Agile Scrum development model
• Tested different functionality of the application like Medicaid eligibility data, state available funds program, Medicaid claim processing etc.
• Understand the overall business model of Medicare Part D products, CMS guidance, and the PBM claim adjudication system.
• Triage critical Workers Compensation claims and ensure the proper involvement by all claim professionals and Business Partners to achieve the best outcome for our employees/customers
• Involved in Design, analysis, Implementation, Testing and support of ETL processes for Stage, ODS and Mart.
• Worked as a part of scrum team, in an agile methodology with sprint cycles, daily stand ups and story implementation, large cross functional project and support teams.
• Participation knowledge in the development of Guidewire Billing Center, Billing Center - Policy Center User Stories
• Served as JIRA executive by setting up workflows, configuring fields, screens, permissions, schemes, etc.
• Responsible for evaluating each requirement to see if it can be implemented in EXTOL EDI Mapping Software.
• Project managed all CMS requirements in Enrollment and Billing including Policies and Procedures and Medicare Enrollment Letters.
• Extensively interacted with the designers, developers to ensure functional implementation of business requirements and QA Team in executing Test Plans, Test Scenarios and Test Cases for Claim Center Module using Guidewire
• Conducted testing of SQM (Sorian Quality Measure), Siemens' certified EHR portal for Meaningful Use. The initiative propelled SQM to a Natural Language Processing and enhanced its capability to capture "unstructured data".
• Performed system analysis on Guidewire Billing Center 8.0.3 based on each user story and presented results to SME's.
• SDLC- Iterative Model & CMMI Level 3 / (ESD) CMS IT Integrated Investment & System Lifecycle.
• Utilization of CMS technology to identify trends in payments by various types of insurances like Commercial, Federal, Workers Compensation, Managed care.
• Prepared ETL standards, Naming conventions and wrote ETL flow documentation for Stage, ODS and Mart.
• Worked on broad range of technologies, including business process tools such as Microsoft Project, Primavera, Promodel, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Be the knowledge leader and subject matter expert of the fundamental underpinnings of workers compensation laws in the jurisdictions assigned
• Involved in Scrum development process and prepared Sprint burn down chart, product catalog and sprint backlog contain Business Requirements and supporting documents that contain the essential business elements and definitions as well as the tasks to be completed.
• Worked in FACETS Reconfiguration of member/subscriber, Data Element Definition and Usage with values and completed configuring FACETS Applications like Related Entity, Parent Group, Group, and Subgroup using IVSTech Data Toolset.
• Working with clients to better understand their needs and present solutions using structured SCRUM approach
• Involved in mentoring specific projects in application of the new SDLC based on the Agile Unified Process, especially from the project management, requirements and architecture perspectives.
• Recorded retention stored in Knowledge Link. Ad Hoc reporting, Admin for MS Project 2003, Excel dbase and pivot tables, Clarity and MS Project Server Admin duties.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams.
• Prepared requirements document for Commercial Auto, Inland Marine, Crime, Worker's Compensation, Umbrella, Business Owners Policy, Commercial Output Policy, and Commercial Property Package.
• Experienced with Rational tools like Rational Req Pro, Clearquest, ClearCase, JIRA, Rational Rose, and FACETS.
• Facilitated application of technology to create and support business solutions, including implementation of wide-sweeping changes that improved the usefulness of the EMR system and the user experience as a whole.
• Performed 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.
• Provided management support to the off-shore End to End Integration / Regression Test Team
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, Cognos, Rational Requisite Pro, MS Office, SQL Server 2005, HTML, DB2, EMR, MS Project, MS FrontPage 2003, MS Access, MS Excel, Business Objects, EDI,TSO/ISPF,UML

Confidential, OWINGS MILL, MD

Business Analyst

Responsibilities:

• Created Business Workflow based on the requirements gathered from the client.
• Created functional specification documents based on the business requirement documents.
• Organized JAD Sessions to resolve issues and conflicts, and to arrive at quick agreements regarding the system architecture design.
• Work closely with production underwriters to review commercial property insurance renewal and new business opportunities to ensure proper risk identification, analysis and assessment and the development and growth of a profitable portfolio of business.
• Knowledge of Guidewire integration framework and various integration methods like Web service APIs, Plugins, Messaging code, Guidewire XML models, templates etc.
• Observed and analyzed corrections-specific workflows to adapt the EMR and optimize provider efficiency and success.
• Assembled business requirement documents (BRD) and the functional specifications as per the user requirements.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.
• Participated is customer weekly JIRA progress updates.
• This primary goal of the project is to support variety of property and casualty insurance and Life Annuities insurance reporting and analytical requirements of American Family Insurance - WI by establishing Enterprise Data Warehouse EDW Business Intelligence layer.
• Explained Property & Casualty terms, Insurance Rules, Workers Compensation, Claim to the Dev team.
• Supported the physician applications and ordering module during the initial EMR go-live and provided support to end users during maintenance and optimization activities.
• Strong working knowledge in Guidewire Policy Center product & Billing Center.
• Documented complex Business requirements and made process flow diagram for the 837, 270/271, 276/277 & 835 Remittance transactions as per the implementation for the Medicaid claim processing system enhancement.
• Worked with QA to create test plans and test cases based on the business requirements which involved market risk analysis and risk management.
• Effectively manage EHR staff by hiring, developing, training, and overseeing personnel to meet the needs of the practice.
• Worked on Commercial Lines Property and Casualty Insurance including both policy and claim processing and reinsurance.
• Working as Business Analyst on implementation of Guidewire claim Center for Auto, Property, General Liability and Workers Compensation lines of Business
• Tested the accuracy of iHelix inpatient EMR for Stage 1 meaningful use clinical quality measure calculation by using Cypress tool.
• Responsible for developing, support and maintenance for the ETL (Extract, Transform and Load) processes using Oracle and Informatica PowerCenter.
• Responsible for EMR interface development and implementation. Specialised in Nephrology EMR, Internal medicine EMR, Psychiatry EMR, Oncology EMR, Anaesthesia EMR etc.
• Utilized the guidelines and artifacts of the Agile Methodology to develop a detailed implementation process Guidewire Claim Center Integration during different iterations and phases in Software Development Life Cycle (SDLC)
• Participated in solving Billing issues from the FACETS Problem Log for Trizetto and Billing Entities.
• Produced training material and led training sessions for JIRA, Tempo, and Confluence.
• Serve as a point of contact for the client’s stakeholders and provided customer support in addition to team building with on and off shore agile teams.
• Improved and enforced claims handling efficiencies to speed up claims payments and adjust reserves more effectively.
• Developed and implemented policies and procedures which includes process flows, guide sheet for all important responsibilities as part of development of Medicare Operations Manual.
• Analysis and Design of the Trizetto FACETS Data Model to ensure optimal system performance and tuning.
• Experience working on Guidewire Claim Center, Policy Center and Billing Center
• Develop maps in Application Integrator (AI) to translate SAP IDOCs to Edifact for the Supply chain and ebanking business
• Wrote complex SQL queries to extract and validate the data from the Facets database.
• Maintained clear understanding of project goals among stakeholders by conducting walkthroughs and meetings involving various leads from BA, Development, QA and Technical Support teams.
• Reviewed high-level design specification, ETL coding and mapping standards.
• Interacted with the client and the management teams to understand the requirements and to report the status of the testing efforts on their applications.
• Lead abstraction of core measure data from EHR and submission of these data to CMS. Data converted to knowledge and wisdom contributed to the establishment of objective measurement, performance transparency, best practice sharing, and standardization.
• Extensive skill on Guidewire Billing Center, Policy Center and Claims Center integrations.
• Utilized Visio diagrams, data flow diagrams, use case diagrams and process flow diagrams using the CMS-MITA guideline.
• Analysis and documentation of the business requirements for Policy conversion to Guidewire Policy Center at the time of renewal.
• Created reports and dashboards in JIRA to track hours and project status to report to finance team.
• Conducted individual and group joint application development (JAD) sessions with business stakeholders and technical units.
• Analyzed “AS IS” and “TO BE” scenarios, designed new process flows and documented the business process and various business scenarios.
• Worked as functional Analyst in the software development team for outsourcing Electronic medical records (EMR) and paperless office system implementation to the medical facilities.

Environment: MS-Visio, MS Word, Excel, PowerPoint, Java, Oracle, Requisite, Web Logic, EMR

Confidential, Virginia Beach, VA

Business Analyst

Responsibilities:

• Assisted QA team by reviewing test cases and clarifying requirements to ensure complete coverage of requirements, worked in Agile environment and was able to bring projects to completion.
• Research Medicaid and Medicare requirements for system automation.
• Designed new database tables to meet business information needs. Designed Mapping document, which is a guideline to ETL Coding.
• Technically competent in Workers Compensation Case Management including complex claims, disputes, Regulatory matters, common law and litigated claims
• Worked on UAT testing and took signoff from the Commercial line of Property Casualty business users.
• Business domain knowledge of Property and Casualty Insurance including risk, Policy Sales, Policy Administration System, Receivables and Payments, across different lines of business.
• Assist in creating and updating tickets in JIRA, along with implementing improvements in Jira to track and produce metrics for all phases of Intake and Development processes.
• Thorough knowledge of EMR. Front end user interface and back end database.
• Worked on Regulatory Reporting RRD Data Warehouse for compiling Workers Compensation statistical reports to external regulators and states.
• Prepared client process maps for the consumer, broker, employer and provider transactions for the Facets process.
• Involved in design and implementation of entire EDI system and produced System Design documentation
• Designed High level design, for New process, integrating with legacy and Facets
• Worked efficiently and effectively with EDI Administration to implement maps and ECGateway processes.
• Maintained JIRA team and program management review dashboards.
• Working closely with Business, Product Management and development engineers to understand Guidewire claim Center features, performing Gap analysis to identify features, gathering and analyzing business requirements
• Solely managed our Jira Service Desk, triaging and escalating production issues as needed.
• Worked on the Guidewire Policy Center 8.0, Billing Center 7.0, Claims Center 8.x/7.x
• Maintaining knowledge of Medicare and Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations.
• Worked with business leaders to translate business requirements and processes into test cases according to Facets package requirements and subsequent effective configuration.
• Worked in Agile environment allowing teams to deliver project piece-by-piece and make rapid adjustments as needed. Good understanding working in Agile and bringing projects to completion.
• Worked with claims and configuration departments to resolve and reduce provider issues by analyzing and researching Medicare and Medicaid guidelines, fee schedules, and provider credentialing, contracting and licensing requirements
• Single Handedly Automated Benefit Enrollment and Maintenance (X12 834) for DST Health Solution’s Client Community of Heath care of Connecticut while at on-site. Received appreciations from Director, Project Manager, and Team Lead of EDI Services for flawless execution of the project.
• Performed Integration testing with Guidewire Claims System and Guidewire Billing System.
• Identified gaps and performed gap analysis with respect to CMS requirements.
• Performed Manual Testing and Involved in Functional, Black box, Usability and Regression Testing for UAT (User Acceptance Testing) and SIT (System Integration Testing).
• Experience on Guidewire's UI testing in Policy Center and Billing Center Screens for Personal lines business Defined the page layouts, reports templates and dashboard layouts for reservation monitoring and for gathering usage statistics
• Created Mapping Documents, Report Mockups and modified existing report mockups as to CMS requirements and finalized for development.
• Worked on testing the scenarios where individual might be eligible for Claim Adjustment under Medicaid Program.
• Created functional routines and verify their reliability to ensure compliance of business rules and propagation of data definitions.
• Maintained JIRA team Confluence System Engineering pages that included: Process Flow Management, Team Requirements, Roles and Responsibilities, and COP User Metrics.

Environment: Windows XP, Facets, RUP, UML, SQL, EMR, Rational Tools, UAT, MS Visio, XML, MS Word, Excel, PowerPoint, Access.

Confidential, Charlotte, NC

Senior Business Analyst

Responsibilities:

• Gathered and documented requirements for creating bureau reports and Bureau Reporting
• Conducted analysis studies that serve as input to the strategic planning, goal setting, and approach to achieving the goals.
• Helped the PM in initiating the project, preparing the Business case and planning it.
• Defined existing business process (BPM-Business Process Modeling) and identified the gap (Gap Analysis) between the existing & improved business process.
• Have worked in Guidewire Policy Center from End-to-End and involved in Policy Info, Person Info, Losses and Violations, Coverage's, Risk Analysis Customizations.
• Processing of New Business, Renewal, Cancellation, Reinstatement, Billing for various lines of business Fire, Auto, Commercial
• Extensive understanding of the international corporate and commercial insurance markets & products / services
• Identified and defined Business analyst work Strategy and requirements risk approach and determine planning considerations finalized (RUP).
• Collected requirements (using) Brain storming, Document analysis, Focus Groups, Interface analysis, Interviews, JAD, prototyping, survey, reverse engineering and user task analysis for various reporting types like CLUE (Comprehensive loss underwriting exchange, Change Report, Claim Count, Claim summaries).
• Worked in the analysis and implementation of COTS software which helped the enterprise teams take right decisions.
• Performed COTS evaluation between different lines of business.
• Explained the solution model, analyze the functional requirements, prepared the Use cases, defined user profiles, defined the supplementary requirements, defined assumptions and prepare the traceability matrix and validate the requirements.
• Develop and execute regional underwriting strategy in line with the global Commercial Insurance LoB strategy
• Domain knowledge of insurance industry with very challenging and demanding work environment. Broad experience in Property and Casualty Insurance including Auto, Home, and Marine Life insurance/Annuities.
• Wrote business requirements specification (BRS) and functional requirements specification (FRS) documents as per the business requirements and process flow.
• Created Business Intelligence reporting for better understanding of business process and data.
• Assisted System Architects and Quality Assurance Analysts in creation of various tests by using Quality center.
• Assured that all artifacts are in compliance with corporate SDLC policies and guidelines.
• Assisted in deletion of defects and bugs, in order to meet specific requirements and deadlines for successful execution of the project.

Environment: Visual Basic, Oracle 11i, MS-Project, MS-Visio Windows Server, Windows, Rational Tools, COTS, RUP, HPQC