PROFESSIONAL SUMMARY:

• Healthcare Business System Analyst with 7 years of experience in the Healthcare Industry on various areas like Claims Processing, Configuration, Billing, Insurance and Reimbursement, Medicaid and Medicare Services, and Pharmacy Benefits Management.
• Over six years of consistent experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, System Change Document, Functional Specifications, experienced in writing Use Cases.
• Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be'/'Go-To' processes.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Experience in Mapping ICD 9 codes with corresponding ICD 10 Diagnosis and Procedure Codes.
• Experience in developing and imparting pre and post implementation, conducting GAP Analysis, User Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis.
• Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820Companion guides.
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements.
• Strong experience with different project methodologies including Agile-Scrum Methodology, Waterfall, Modified-Waterfall, Iterative, Incremental and RUP.
• Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834 (Benefit Enrollment 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).
• Expertise in Data Analysis Activities including Enterprise Data Management (EDM), Data Profiling, Data Quality, Data Governance, Source to Target Data Mapping, Data Testing.
• Rich experience in quantitative analysis and data mining using Excel, SAS and SSAS.
• Developed predictive analysis and models with data mining techniques using SSAS and SAS.
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.

TECHNICAL SKILLS:

Business Analysis Tool: MS Visio, Rally, MS Project, MS SharePoint

Test Management: MS Project Test Scheduling, HP Quality Center, ALM, TSS Traceability Matrix for Requirements and Defects

Testing Tools: HP ALM

ETL Tools: Informatica, SSIS

Data analysis and mining tools: SAS, Stata, R, SQL Server Analysis Services (SSAS), Excel

IBM Rational Suite: Rational Functional TesterBug Reporting Rational Clear Quest, JIRA

Version Control: Rational Clear Case, JIRA

Scripting languages: VB Script, HTML, Shell Scripting

Operating Systems: Windows XP/NT/2000/Vista/7, DOS, UNIX

Databases: Oracle 10g/9i, MS SQL Server, IBM DB2, TeradataV2R6, MS Access

MS Suite: MS Office 2007 (Word, Excel, PowerPoint, Outlook), MS Visio, MS Project

SDLC: Agile, RUP

PROFESSIONAL EXPERIENCE:

Confidential, Dallas, TX

Sr. Business System Analyst

Responsibilities:

• Gathered Business Requirements from the Business users, Subject Matter Experts (SMEs) and document the requirements in the BRD.
• Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Participated in all Iteration, Scrum, Daily stand-ups and Iteration review meetings working in an agile development methodology.
• Involved in gathering, documenting and verifying business requirements.
• Organized JAD Sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system.
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the proposed system.
• Served as a liaison between the internal and external business community (Claims, Billing,, Capitation, Customer service, management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Worked extensively on the EDI Transactions via EDI 270, EDI 271, EDI 276 EDI 834, EDI 835, EDI 837
• Analysis of inbound and outbound interfaces and extensions to Trizetto’s FACETS Claims Processing system.
• Involved in claim adjudication process of facets application.
• Worked on the EDI 834-file load to Facets through MMS ( maintenance sub-system)
• Involved in claims submission and payment (remittance) retrievals by using ASCX12N 820 for the In- bound premium payments; ASC x12N 834 for the Inbound Enrollment and Maintenance; ASCX12 276/277 for the claims status enquiry and response; and ASC X12 835 for the Health care Claim Payments.
• Recommend ways and workarounds for HIPAA 5010 (EDI X12 837,834, 820, Reviewed HIPAA 270/271, 276, 277, 835, 837, and 820 standards for the process and products developed.
• Worked on Data Mapping to map Facets data to outbound eligibility extracts.
• Worked on FACETS subsystem such as billing and enrollment.
• Collected business requirements to set rules for proper data transfer from Data Source to Data Target in Data Mapping
• Worked with the ETL specialists to migrate data into DWH & involved in data modeling.
• Performed Data Analysis to make sure its correctness and completeness in test environment.
• Researched the existing client processes and guided the teams in aligning with the HIPAA rules and regulations for the systems for all the EDI transaction sets.
• Ability to analyze business rules, perform data mapping and guide to create ETL processes.
• Created new and modify existing SQL server queries, views, packages, and ETL jobs.
• Worked closely with stakeholders and SME’s for requirements gathering.
• Identified end to end requirements for all systems and business units that may be impacted by the project.
• Developed requirements integrating Use Case diagrams and designed the testing process flows.
• Established and maintained traceability matrix until business requirements were signed off.
• Conducted walkthrough and lead work sessions.
• Developed a Business Acceptance testing strategy and plan.
• Created test files and analyzed test results using MS-Excel.
• Involved in Claim Processing from End to End and major work was involved with 837 P/I Claims Processing systems.
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Coordinated and facilitated the execution of User Acceptance testing.
• Used tools such as SAS/Access and SAS/SQL to create and extract oracle tables
• Key role in data analysis, relation modeling and data migration, query tuning /Optimization.
• Involved in data warehouse design/development.
• Performed Data Analysis, Data profiling and Data validation by writing SQL queries using TOAD.
• Used Microsoft Word, Excel, Access and Visio as working tools.
• Wrote SQL queries to validate source data versus data in the data warehouse including identification of duplicate records.
• Extracted data from existing data stores, Developing and executing departmental reports for performance and response purposes by using oracle SQL, SAS, procedures, packages, functions, database triggers
• Responsible for managing the Data Warehouse and Business Intelligence functions.

Confidential, Philadelphia, PA

Business Analyst

Responsibilities:

• Analyzed Business Requirements and segregated them in to high level and low level Use Cases, Activity and Sequence using MS Visio according to UML Methodology.
• Conducted JAD sessions with project's stakeholders such as users, QAs and project management team to identify and resolve issues.
• Performed GAP analysis as pertains to management and claims processing to evaluate the adaptability of the new application with the existing process
• Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
• Conducted Claims and HIPAA Compliance to run the test cases. Also worked with NPI
• Experienced in X12 transactions 835/837/834/820/271 of medical claims/underwriting for support and point of for the vendor in business issues.
• Worked on Member Management, Eligibility, Claims, and Provider modules within FACETS.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML.
• Completed Data Mapping for Group and detail Product analysis and report writing
• Manage RTM (Requirement Traceability Matrix) to track the project flow.
• Prepared BRD and Derived Functional Requirement Specifications (FRS) based on User Requirement specifications and delivered to the project team. Understand and articulate business requirements from user interviews and then convert requirements in to technical specifications
• Used guidelines and artifacts of RUP to strategize the implementation of the Rational Unified Process effort in different iterations and phases of the Software Development Life Cycle (SDLC).
• Configured facets modules such as Claims,, Billing, Benefit and plan.
• Utilized TriZetto Facets to verify Electronic Data Interchange (EDI) Transactions 834 ( Enrollment), 835 (Enrollment of Benefits), and 837 (Claims Processing) were compliant with HIPAA standards.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Involved in Data Analysis, Data Validation, Data Modeling, Data Profiling, Data Verification, Data Mapping, Data Loading, and Data Warehousing/ETL testing.
• Used SAS as an ETL tool to load data from flat files and databases into SQL Server and Teradata environments.
• Microsoft Office (Outlook, Word, Excel, Visio, Access) at various phases of development for documenting the requirements.
• Documented the Use Cases and prepared the Use Case and Activity Views using MS Visio and Rational Rose for a clear understanding of the requirements by the development team.
• Created new, and modify existing SQL queries for use in the data integrity testing of the data warehouse application's ETL process.
• Wrote macros, developed concise SAS scripting and used SQL to concatenate and join
• Developed timelines for project delivery, and managed projects and resources to successful completion.
• Conducted workgroup sessions with client and security team to analyze system role-based access and panel security.

Confidential, Healthcare, KS

Business/System Analyst

Responsibilities:

• Facilitated JAD sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system
• Identified processes for developing and documenting detailed business requirements.
• Involved in gathering the requirements that were critical to the business process flow and using those requirements for the Business Requirements Document (BRD).
• Formulated Business Requirements using Agile / Scrum methodologies to decompose requirements into Epics and User Stories iteratively
• Gathered requirements through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts and other potential users of the application.
• Created Use Cases and Requirements documents to document business needs.
• Worked with Business analyst and IS teams to understand the flow of data.
• Participated in management level status report meetings, in addition to participating in concept, design, build and implementation of Pega Modification Portal.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• ICD-10 remediation in alignment with GEM Mapping, Reimbursement Mapping, and Forward/Backward Crosswalk concepts.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Validated the following: 834 (Health Care Claims or Encounters), 834 (Health Care Claims payment/ Remittance).
• Elicited, documented, verified, and validated all Pega Modification Portal letter requirements.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) report.
• Performed detailed analysis for the following functional areas that is going to be impacted by ICD-10 codes.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems as well as for ICD 9 to ICD 10.
• Conduct ICD-9/ICD-10 conversion analysis through ICD 9 and ICD 10 proposed mapping documents and HIPAA 5010 system capabilities of EDIFECS tools. Update mapping documents as required for version upgrade and change requests.
• Created and maintained SQL Scripts to perform back-end testing on the oracle database.
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Identified Use Cases from the requirements and create UML Diagrams including Use Cases, Activity/State Charts, Sequence diagrams, and Data Flow Diagrams using MS-Visio thus defining the Business Process Model and Data Process Model.
• Experience in SQL joins, sub queries, tracing and performance tuning for better running of queries.
• Responsible for installation of SQL Server, database design, and create schema objects like tables, views and indexes.
• Extensively used joins and sub queries for complex queries involving multiple tables from different databases.
• Performed data analysis from the data warehouse along with business intelligence solutions delivery team.
• Delivered ad hoc reports using SSRS, SAS, and standard SQL queries.
• Used derived tables, Sub-query wrote SQL queries to extract data from SQL server and Teradata.
• Performed extensive task which include Data Quality Analysis, Data lineage and Data Standardization data structures, data base design, data warehouses, business intelligence/analytic tools, SQL, ETL tools, and data integration methods.

Confidential, Washington, DC

Business Analyst

Responsibilities:

• Gathered requirement and converted in to technical requirement document.
• Helped business leaders understand business requirements and performed gap analysis relative to industry standards and future directions for strategic initiatives.
• Acted as a liaison between Business area Subject Matter Experts (SMEs) & development team throughout all phases of SDLC; starting from Inception to Transition phase Agile/Scrum Methodology.
• Extensive experience and knowledge for defining the scope of the project, gathering business requirements and preparing Business Requirement Document (BRD), and Functional Requirement Document (FRD)
• Identified, Evaluated and recommend solution alternatives analysis
• Worked with development organizations to ensure successful implementations of designed solution.
• Prepared, Presented, and collaborate on all required deliverables of the technical team.
• Documented high level technical design to enable the integration and implementation of the solution.
• Responsible for understanding the strategic direction, priorities and needs of business leaders.
• Create and maintain templates, schedules, estimates and models
• Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277 P, 837I, 837D, 835 remittances)
• Create and maintain technical documentation for architecture, systems, vendor solutions and strategy.
• Coordinated with other project managers and staff to identify cross-project dependencies.
• Coordinated activities of multiple vendors and SME’s and assist in developing Service level Agreement.
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Determined cost factor involved in integration process of third party vendors.
• Create and identified USE Case from the business requirement.
• Create and maintained Software Architecture Document and Logical Solution Design.
• Organized JAD Sessions to resolve issues and conflicts, and to arrive at quick agreements regarding the system architecture design.
• Used Microsoft Word, Excel, Access and Visio as working tools.
• Worked extensively with Tableau and MS Excel for the generating of reports.
• Assisted team with Data Mapping and Data Extracting Strategies for data migration.
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio
• Participated in various meetings and discussed enhancement and modification request issues.
• Actively participated in enhancement meetings. Involved in the meeting with Business process owners, SME (subject matter experts) and Marketing Team for Requirements gathering in definition stage.
• 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.
• Used MS Project for status reporting and planning.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Extracted data from Teradata and Oracle and created pivot tables in Excel.
• Involved in Deep Dive analysis of implementing new functionality in the Cost Estimation Engine.
• Heavily worked with various group to identify their need to determine different level of integration.
• Interacted extensively with the third party vendor and the management teams to understand the requirements and to report the status of the assessment effort to the audience.