PROFESSIONAL SUMMARY:

• 6+ years of Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollment and eligibility processes.
• Firm ability to research, analyze and translate complex business and technical information to stakeholders, SMEs, and developers at all levels of the organization. Also, in Defining, Gathering, Documenting, and Managing requirements to identify the real business need of the client company.
• Excellent communication, interpersonal consulting and facilitation skills.
• Working expertise in Software Development Life cycle (SDLC), Project Life cycle, Business Process Modeling (BPM), Software Development Methodologies including Rational Unified Process (RUP), Waterfall, Spiral, and Agile with SCRUM process
• Organized in Joint Application Development (JAD) and Rapid Application Development (RAD) sessions with business/end users, expert team and technical team.
• Developed use case diagrams, sequence diagrams, state diagrams and activity diagrams, business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML).
• Experience in producing documents like Business Requirements Documents (BRD), Functional Requirement Documents (FRD), Software Requirement Specifications (SRS), Creating Request for Proposals (RFP), creating Requirements Traceability Matrix (RTM)
• Experience in creating Prototypes and Wire frames and documenting them using MS Visio and Enterprise Architect
• Involved in all phases of Testing life cycles including integration testing, User Acceptance testing (UAT) Functional testing/Black Box Testing, Regression testing, GUI testing, and performance testing.
• Hands on experience with Object Oriented Analysis and Design (OOAD); work side by side with technical managers; senior design engineers/ analysts; used UML extensively with emphasis on Use Case diagrams, state diagrams, sequence diagrams, activity diagrams and collaboration diagrams using Rational Rose and MS-Visio; solid hand-on experience working with MS Excel, writing very complex Excel macros to pull data in Data Mining and Data Warehousing environment; help in designing the ETL processes.

TECHNICAL SKILLS:

Methodologies: Agile, Waterfall, RUP, UML, SDLC, Scrum, RUP, V-shape modelling

Change Management Tools: Rational Clear Quest, Rational Clear Case

Business Modelling & Versioning Tools: MS Visio, Visual Paradigm, Rational Rose; Rational Requisite Pro, Rational Clear Case MS Office MS Project, MS Word, MS Excel, MS PowerPoint, MS Access, Infopath Designer

Programming Languages: Structured Query Language (SQL)

Operating System: Windows NT/98/2000/XP

Databases: Access, Oracle 8i/9i/10g, Teradata V2R5.1, DB2, MS SQL Server 7.0/2000

Other known tools: Informatica, Load Runner, Win Runner, Crystal Ball, Expert Choice, Core, Caliber

OLAP Tools: Business Objects XI, Cognos

Testing tools: Rational Robot, Rational Clear Quest Test Manager, HP Quality Center, Quick Test Professional (QTP), LoadRunner, WinRunner Apps & Webservers Apache web server, Tomcat, Web logic 8.1, IIS.

PROFESSIONAL EXPERIENCE:

Confidential - Holly Hill, FL

Senior Business Analyst

Responsibilities:

• Acted as a primary contact in all the phases of Software Development Life Cycle SDLC, including Quality Assurance Testing, Performance & User Acceptance testing.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/ Medicaid claims processing.
• Worked with the data architecture and data analyst team in designing the model and in creation of the data mapping documents
• Elicited requirements for agile projects by documenting User stories, Product Backlogs and Acceptance Criteria.
• Extensively worked with FACETS Implementation, FACETS Billing, Claim Processing and Subscriber/Member module.
• Used Data warehousing for Data Profiling to examine the data available (Data Analysis) in an existing database
• Involved in gathering requirements, configuration, and data conversion of the Facets application modules like Enrolment, Membership and Claim.
• Participated in frequent agile team meetings (Scrum planning, daily stand-ups, retrospectives) to provide guidance to an agile product development process.
• Involved extensively in writing Agile User Stories and get them reviewed with Business lead and project manager for Sign Off.
• Served as a technical resource for developing protocols used in EDIFECS Transaction Management.
• In depth knowledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors.
• Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• Reviewed System and Integration Testing SIT, Regression Test Cases by using ALM for the Core MMIS's functional areas e.g. Provider, Member, Web Portal, Finance, and Reference.
• Diversified, modernized inventory expanding titles 4x in 12 months. Added Edifecs product and data centre management
• ACA CORE Operating Rules implementation for real time and batch transactions 270/271 and 276/277 using Edifecs XE Connect, XE Server and XEngine for both SOAP and Multipart requests.
• Creation of guideline documents (ecs files) creation using Edifecs Spec Builder
• 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
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management.
• Worked on a Paid without prejudice project for various States. Performed UAT tests using the (MORAE) Usability Testing Tool using the Observer and the Manager Mode.
• Responsible for design, build, testing and implementation for Epic Home Health and Hospice Billing and Clinical applications.
• Writing Epics and user stories, managing sprints and backlog grooming, and tracking project progress in JIRA.
• Expertise in performing Bug and Defect management using bug-tracking tools like JIRA and HP QC/ALM.
• Used JIRA to perform test management activities and used JIRA tool to track and maintain different versions of the project documentation.
• Testing of Epic billing reports (hospital billing and insurance billing) for Epic billing output and interface accuracy.
• Create and execute revenue cycle medication Epic billing data and reports from decision support and billing systems. Analyzed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed
• Responsible for architecting integrated HIPAA, Medicare solutions, and Facets EDI 834.
• Analyzed results and EDI ANSI X12 file mapping and reported on standard analysis spreadsheet. Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts. Acted as a liaison between client and payer/intermediary.
• Developed test Scripts using Quality Center and coordinated with developers to quickly resolve the defects associated with them.
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Experience in Data Validation, Data Modelling, Data Flows, Data Profiling, Data Mining, Data Quality, Data Integration, Data Verification, and Data loading
• Developed several detail and summary reports including line and pie charts, trend analysis reports and sub-reports according to business requirements using SQL Server Reporting Services (SSRS).
• Created source table definitions in the Data Stage Repository by studying the data sources.
• Worked on Data mapping, logical data modelling used SQL queries to filter data within the Oracle database tables.
• Conducted JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications. Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions to test the performance of the application from various dimensions.
• Helped create the 'Business Glossary' to facilitate efficient understanding of the business process amongst the other teams. Assisted in creation of the Functional Design Document from the Business Requirements Document which was used as the reference by the development team while preparing the design and held the responsibility of the required data setup for unit testing.
• Strong communication skills with the ability to communicate appropriately in business and technical situations at all levels. Effectively presented projects using MS PowerPoint.
• Worked extensively on Business Requirements, Functional Specification, Data-Integration, Data Mapping, and Data Warehouse access using SQL and Crystal Reports, ETL process, use cases modelling (UML) using MS Office (Word, Excel, Access, Visio) and dashboards
• Developed new reports using Business Objects/Crystal Enterprises on SQL Server, Oracle and Teradata databases utilizing T-SQL and DTS, focusing on data verification and query performance.

Environment: Rational Unified Process (RUP), Agile (Scrum), Java, Web Services, EDI X12 (834, 835, 270, 271, 837), Microsoft Office Suite, Microsoft Project, IBM Rational Suite (DOORS, MS Visio, Word, Excel, PowerPoint, Rose, Clear Case, Requisite Pro),IBM, Cognos, UML, XML, Java, Microsoft Visio, HP Application Lifecycle Management (HP ALM), TriZetto Facets.

Confidential, VA Beach, VA

Business Analyst

Responsibilities:

• Performed GAP analysis as pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation & Verification process.
• Used Quality Center to plan tests, manages test assets, create and run manual and external scripts to check GUI and functional features of the AUT
• Involved with requirement gathering and analysis for the data marts focusing on data analysis, data quality, data mapping between ODS, staging tables and data warehouses/data
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Maintaining knowledge of Medicare and Medicaid rules and regulations and evaluating the impact of proposed changes in rules and regulations.
• Expertise in the EPIC Medical software application (EMR, EHR) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Created Process Work Flows and responsible for preparing Functional Requirement Specifications Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming & developing questionnaires
• Efficiently worked alongside Project Manager and Lead Business Analyst to determine the Scope and utilized Rational Unified Process (RUP) and Agile (Scrum) System Development Life Cycle (SDLC) methodologies to coordinate and strategize concise solutions within a constricted timeframe involving multiple interfaces.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Developed, designed& implemented department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization.
• Conducted brainstorming sessions with the business users and SMEs to elicit requirements and worked in the creation of Agile Epics, user stories, Acceptance criteria documents.
• Working knowledge of implementing software development projects using methodologies such as Waterfall, Rational Unified Process, and Agile/Scrum.
• Operating Rules implementation for real time transactions 270/271 and 276/277 using Edifecs XE Connect, XE Server and Xengine for both SOAP and Multipart requests.
• Used Edifecs Transaction Management tool to verify that the batch and real-time files are generated correctly
• Used HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) and 820) standards
• Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler
• Strong knowledge of working on JIRA and Utilized it to develop and track agile epics, stories and tasks.
• Performed Defect Tracking and Project Tracking using Jira - Change Notification Request (CNR).
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management
• Participated in changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage
• Owner of the business rules document, which documented the business rules across different systems.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Led and managed the User Acceptance Testing (UAT) for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Involved in the development of Test Plans, Test Cases and Expected Results, and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Tested different functionality of the application like Medicaid eligibility data, state available funds program, Medicaid claim processing etc.
• 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.
• Researched, defined and analyzed changes to both state and federal laws affecting the Medicaid Management Information System (MMIS) for Tennessee Medicaid account
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Worked on Business Intelligence Analytical Reporting (BIAR), the base MMIS data warehouse subsystem, to extract and analyze Medicaid data and to support exchange of this data with various external data sources via a secure SFTP server.
• Performed Data Analysis, Data profiling and Data validation by writing SQL queries using TOAD
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Resolved data issues and updates for multiple applications using SQL queries/scripts
• Responsible for unit testing and working with System/Integration testing team in debugging/resolving any issues raised during testing.
• Created Data Flow Diagrams and Process flow diagrams for various load components like FTP Load, SQL Loader Load, ETL process and various other processes that required transformation.
• Conducted user training pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity (mainly occur with EOPs, capitation rosters, PCP membership rosters, provider directory listings and some system generated letters)

Environment: Rational Unified Process (RUP), Agile (Scrum), EDI X12 (834, 835, 270, 271, 276, 277, 837), Microsoft Project, Java, IBMCognos, IBM Rational Suite, MS Visio, Word, Excel, PowerPoint, UML, XML, Microsoft Visio, Atlassian JIRA, Microsoft SQL, Microsoft Access, Facets.

Confidential, Toledo, OH

Application Business Analyst

Responsibilities:

• Reviewed CMS regulations of EGWP and PDP programs and translates regulations into business requirements.
• Discussed and applied Rational Unified Process (RUP) and Agile (Scrum) methodologies, indicative to System Development Life Cycle (SDLC) with Project Manager and Senior Business Analyst.
• Wrote different SDLC documentation: BRDs, FRDs, Process flow diagram, test scenarios on TrOOP, Co-pay calculations, COB, EOB, Plan finder, Retro Changes and PDE creation and PDE reject handling.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Used Data warehousing for Data Profiling to examine the data available in an existing database.
• Design, development, implementation and roll-out of Micro strategy Business Intelligence applications
• Ability to analyze engineering product support issues described within a bug-tracking system (JIRA) and provide guidance to other Client Services members in an advisory capacity, focusing on the quick resolution of the production issue and using this as a training opportunity for other team members
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence)
• Created and executed test plans that improved data warehouse report quality using Word, Excel and Access.
• Used Edifecs Transaction Management tool to verify that the batch and real-time files are generated correctly.
• Utilized TriZetto Facets for mapping coordination of EDI Transactions 834 (Membership Enrollment), 835 (Enrollment of Benefits), 270 (Benefits Inquiry), 271 (Benefits Responses), 276 (Claim Status Requests), 277 (Claims Status Notification), 278 (Healthcare Services Review Information), and 837 (Claims Processing).
• Amisys migration, implementation and conversion team ñ analyze legacy system and develop use cases for Amisys implementation, validate converted data, create codes sets to be used across all subsystems, configure pricing, benefits and provider subsystems, data mapping, interact with developers.
• Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them.
• Worked on automating Forward Curve calculation application that allowed internal users and managers to predict the daily, monthly, quarterly and annual commodity price (green energy) based on market value and previous years data.
• Provides interpretation of business rules and requirements for technical system upgrades while tracking progress.
• As part of a team, provided business analysis to convert Medicare program for PPO on Amisys systems to the GHI PPO mainframe. This included requirements from the business / vendors plus program specifications to transfer membership/claim/provider data to the PPO.
• Performed Data analysis from the data warehouse along with business intelligence solutions delivery team.
• Working knowledge of Epic Rx /Epic Lab/Epic Care Inpatient/Health Information Management and Chart Tracking.
• Extensive healthcare experience in Medical Imaging, EHR/EMR, Mobile Apps, Medicare-Medicaid, HIPPA, HIX on EPIC software applications.
• Reviewed existing functional practices and recommends modification to processes or new strategies in meet business requirements.
• Involved in testing and reporting of errors of subsequent builds during the process of development and production.
• Worked with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects.
• Created detailed mapping documents and technical specification documents mapping the fields between multiple databases and the reporting data warehouse.
• Align with the BOs for defining test scenarios; workflow (or business process flows) and training processes.
• Extensively involved in testing Trizetto's Facets and mainly involved in Enrollment and Eligibility modules.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Worked on preparing sprint backlog and user stories in agile scrum methodology with business users, developers, and stakeholders.
• Helped database architects define the various fields necessary and create database structure.
• Involved in the PDE design session, provided support to development team in PDE creation as well as PDE reject handling process.

Environment: Rational Unified Process (RUP), Waterfall, HIPAA, EDI X12 (834, 835, 270, 271, 276, 277, 278, 837), Java, IBM Rational Suite (DOORS, Rose, Clear Case, Requisite Pro), UNIX, UMLMS Visio, Word, Excel, PowerPoint,, Axure RP, Application Lifecycle Management (HP ALM), Microsoft SQL, Microsoft Access, TriZetto Facets.

Confidential, Washington DC

Business Analyst/Data Analyst

Responsibilities:

• Responsible for the delivery and successful implementation of the project from the beginning to rollout to production support. Project involved 20 FTE from IT over a period of one year.
• Responsible for planning/ organizing/ coordinating/ conducting JAD sessions with users (Membership, Billing, Claims, Sales & marketing and Underwriting) spread across different locations in USA and IT Groups.
• Defined project, programmer and summary specifications, software test plans, data conversion process and implementation plans to clients and programmers.
• Analyzed business user needs, designed and developed interfaces needed to implement HIPAA EDI 837 (Healthcare Claim) transaction to send to health insurance companies.
• Responsible for summarizing and communicating the minutes of JAR meetings to all the stake holders. To gather the requirements from the Business users across various groups.
• To perform Gap Analysis on the existing system with an idea of figuring out the necessary mapping steps towards the new "Target" system.
• Involved in workshops / training / presentations, assisting in the preparation of user and system test plans.
• Created Expected results by querying production database, and executed the same SQL queries on the test databases to compare the actual vs expected during the system testing and user acceptance testing.
• Developed, coordinated, and implemented methodology and scope for multiple complex projects.
• Utilized strong analytical and research techniques to identify gaps and inconsistencies within current measurement tools, allowing development of improved and cost-effective business models.
• Collaborated closely with SMEs to identify and analyze core requirements and key features of the ongoing telecom, media and call center operations projects
• Providing a link between the company, customer, the development team and any third-party regarding software functionality throughout the development cycle.
• Interfaced with business users to prepare and update Business Process Requirements (BPR) and Software System Requirements (SSR). Created test cases and test scripts.
• As an IT professional focusing mainly on the core-business of healthcare IT-HL7 Interface analysis and integration of applications (e.g., EHR, PHR) from clinical and public health perspective to help providers in their quest to achieve meaningful-use. And promote self-management of chronic diseases (diabetes, cancer) that improves quality of patient care.
• Experience with EPIC user and provider record provisioning, including the development of role-based access, security classes, and user profiles.
• Responsible for creating and reviewing business requirements, functional specifications, project schedules, technical documentation and test plans. Prepared documentation showing the AS-IS process flow of Claims systems per CMS (Center for Medicare) request.
• Performed GAP analysis of business rules, business and system process flows, user administration, and requirements.
• Project owner for the Business Process Improvements from IT Perspective; conducted gap analysis; presented CBA (Cost benefit analysis) report to the senior management; designed and implemented the changes through the operations and IT organization
• Validated member eligibility and eligibility inquiry in the facets application to the legacy application in order to confirm the migration successful or not.
• Involved in testing Claims payment and implementation, HIPPA compliance ANSI X12-837 EDI Transaction Code 837-claims encounter, 834- Benefit Enrollment, 835 - Claim Payment.
• To validate the data fixes and carry out the UAT with the Business users before releasing to Production environment; responsible for User Sign-offs.
• Responsible for collection of metrics during the life cycle of the project; provide them to the senior management on a regular basis; communicate to PMO.
• Used JIRA to perform test management activities and used JIRA tool to track and maintain different versions of the project documentation.
• Strong knowledge of working on JIRA and Utilized it to develop and track agile epics, stories and tasks.
• Responsible for evaluation of different technology choices and presenting the recommendation to the senior management for their approval.
• Responsible for production support issues post-implementation; responsible for daily meetings, review of tickets, identifying the solution and implementation of solutions as needed.
• Responsible for day to day coordination of tasks with on site as well as off shore teams; plan based on the cultural issues pertaining to off shore teams; be available to the off shore team beyond hours.

Environment: Facets Trizetto, .Net, SQL Server, Clinical Care Advance Trizetto, Business Objects XI R, Data Stage, ERwin, Mainframe, DB2, Clear Quest, Remedy, MS Word, Instructional design, Adobe Captivate, Excel, Excel Macros, VB scripting, MS SQL, SQL Queries, SQL Navigator, SQL Advantage, Toad, ETL - Informatica, Oracle 10g, MS Project, Vision, SQL Analyzer.