SUMMARY:

• I am a 6 - year veteran IT professional with experiences working in retail e-commerce web development, Pharmacy Benefits Management to more recently being part of Facets implementation in Oregon, MA-HIX/HIE and Confidential and ESI merger.
• Performed Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts using UML diagrams
• Validated EDI Claim Process 837I/P/D, 835 payment advice, Coordination of Benefits(COB), EOB, batch processing, mass adjudication and batch corrections using Facets™ medical and hospital claims processing modules, according to HIPAA compliance.
• Excellent knowledge of Medicare (Part A, B, C and D) and Medicaid Health Insurance Policies, MMIS and reimbursement forms
• Worked with HIPAA Team for RIMS Companion Guide of X12 ANSI 270/271 and 276/277 Companion guides for Professional and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving EDI 837 HIPAA compliance and EDI 835 Remittance Advice.
• Worked on HIX member's enrollment, billing claims and customer services process that are required to participate in the Oregon State’s state-funded health insurance exchange (HIX) in compliance with the Patient Protection and Affordable Care Act (PPACA)
• Worked on creating a new linked provider directory and patient record locator service that allows for effective handoff between clinical and administrative exchanges (HIX, IES and HIE) and Massachusetts Medicaid.
• Worked on Benefit Plans, Claims Payment Cycle, Waiver Programs and, Obama Care, Affordable Care Act (ACA) Applications, Facets configuration, Billing applications, Life Insurance Application, Managed Care Organization system, Epic applications, MMIS, Medicaid and Medicare claims and Eligibility processing systems.
• Worked on leveraging the MA Virtual Gateway (MVG) services for all three Massachusetts exchanges (HIX, IES and HIE).
• Worked to streamline work flow processes, eliminate redundant data entry, and support patient communication activities. Worked extensively with SQL Server for data mapping and data validations using complex SQL queries.
• Tested new edits introduced by the new benefits build out such as drug-to-drug interactions, duplicate therapy, and dose checking through the use of third-party database files and reported bugs on HP QC/ALM (Quality Center)
• Involved in handling production issues of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for generating reports.
• Tested new edits introduced by the new benefits build out such as drug-to-drug interactions, duplicate therapy, and dose checking through the use of third-party database files and reported bugs on HP QC/ALM (Quality Center)
• Performed manual testing at all stages of development: test, QA, UAT, PROD

SKILLS/LANGUAGES:

Facets 4.71/ 5.21, Amysis 4.0, XCLAIMS, AS400, Visual Studio 2010, Selenium, JUnit, Team Foundation Server(TFS), SharePoint, Clarity, JIRA, Confluence, Oracle 10g/11g, SQL SERVER 2008/2012, TOAD, MySQL, MS Access, MS Project, VersionOne, Rally, IBM DOORS, Rational Requisite Pro, Rational ClearQuest, Rational ClearCase, IBM RQM, DreamWeaver, Balsamiq, Informatica PowerCenter, SQL Server Management Studio 2012, MS Visio, Sparx Enterprise Architect, Edifecs SpecBuilder, Transaction Manager.

WORK HISTORY:

Confidential, Buffalo, NY

Business System Analyst

Responsibilities:

• Analyzed and identified the requirements from Group Class Plan (GCP) document for member and subscriber demographic information and the insurance plans.
• Sr. Systems Analyst for Enrollment and Claims business area for Facets Implementation and maintenance projects.
• Responsible for writing the Test Cases and Test Scenarios based on the Business Requirement Document (BRD) and technical Specifications and loaded in Jira.
• Coordinating with Business users and Business owners to gather first level of requirements for Enrollment and Claims business areas.
• Identified issues with the testing tools and the environment configurability and reported to the Lead.
• Provided regular status updates to Team Lead on high priority issues and Testing Progress.
• Experience in integrating claims, eligibility, provider and data information using facets
• Conducted analysis, assessments and cost/benefit analysis using facets
• Logged defects, determined repair priorities and tracked the defects until resolution.
• Maintained a traceability matrix of the requirements and the associated test cases and the defects logged.
• Created wire frames for reporting portal.
• Expert in developing BRD (Business Requirement Document), TRD (Technical Requirement Document), URS (User Requirement Document) and FRS (Functional requirement Specifications) following Agile methodology.
• Prepared SQL queries and generated security reports.
• Created source, target, and process models to load data with Data Warehouse Center.
• Developed data conversion strategy for data migration from MS Excel to MS Access
• Involved in API technical writing for both SOAP and REST. Documented XML and JSON request and responses.
• Performed Data Validation with Data profiling.
• Involved in extensive Data validation using SQL queries and back-end testing.
• Responsible for completing functional testing and regression testing for Core Facets, interfaces, extensions, reports and letters.
• Worked in conjunction with the Data Architect, ETL Developer and BI team on creating the Mapping Design Document.
• Perform user acceptance testing (UAT) to ensure the business intent is correctly implemented in Facets.
• Updated detailed market specific requirement in Confluence.
• Worked with the testing team to understand the Facets Claim adjudication process in order to ensure that they prepare valid test scenarios.
• Worked with business leaders to translate business requirements and processes into test cases.
• Coordinated with the developers on Defects Status on a regular basis.
• Involved in User Acceptance Testing.
• Wrote User Stories and technical requirements.

Confidential, Portland, OR

Facets Business Analyst

Responsibilities:

• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts using UML diagrams
• Conducted one on one interviews with high level management team and participated in the JAD/JAR/JRP session with the SME’s.
• Worked in association with RUP mentors to ensure fidelity to the standard RUP practices of the institution.
• Validate EDI Claim Process 837I/P/D, 835 payment advice, Coordination of Benefits(COB), EOB, batch processing, mass adjudication and batch corrections using Facets™ medical and hospital claims processing modules, according to HIPAA compliance.
• Designed Use Cases using UML and managed the entire functional requirements life cycle using RUP.
• Created and managed project templates, Use Case project templates, requirement types and traceability in Rational Requisite Pro.
• Excellent knowledge of Medicare (Part A, B, C and D) and Medicaid Health Insurance Policies, MMIS and reimbursement forms
• Worked with HIPAA Team for RIMS Companion Guide of X12 ANSI 270/271 and 276/277 Companion guides for Professional and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving EDI 837 HIPAA compliance and EDI 835 Remittance Advice.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS Visio.
• Implemented Standardized and Unified process throughout the software Development Life Cycle (SDLC).
• Involved in Trizetto Facets System Administration, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837.
• Validated member’s benefits against the benefits matrix.
• Worked on Member Management, Benefits, Eligibility, Claims, and Billing modules within Facets.
• Responsible for build and unit testing for NetworX Pricer Provider Agreements, rate sheets, qualifier groups, routing rules.
• Performed application configuration for Facets NetworX Pricer utilizing existing pricing arrangement available in various pricing systems. Worked with FACETS, e Billing and EDI HIPAA Claims (837/835/834) processing.
• Conducting analysis, configuring, testing, quality assuring and documenting configuration solutions for all applications in the Facets system. Executed SQL queries for verification, update, and delete Products Components for Benefit Configuration in Facets
• Involved in handling production issues of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously.
• Performed testing on pricing changes and benefit configuration changes. Create and Update Fee Schedules
• Extensively worked in writing T-SQL, Functions, Stored procedures, database triggers, exception handlers, DTS Export & Import.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for generating reports.
• Worked on the EDI 837-file load to Facets through MMS ( maintenance sub-system) and through flat files.
• Worked on setting up and configuration of Regence plans for their private exchange which provides employers with consumer decision-support tools

Confidential, Boston, MA

Facets Business Analyst

Responsibilities:

• Gathered functional and non-functional requirements in collaboration with end clients and project managers, as well as SME(s)
• Created detailed business scenarios and writes master use cases which covers step by step process of interaction between user and system for HIX enrollment and Maintenance from JAD sessions for Medicaid eligibility, QHP & SHOP plan selection
• Involved in 834 initial enrollment and maintenance and Special Enrollment Period (SEP) user scenarios using MS Visio
• Worked on Coordination of Benefits - Calculations using Total charges, Facets allowed,
• Worked on Claims Payment and Adjustments - Claims inquiry, Remittance, Explanation of Benefits, Discounts, Interest calculations, Split payment etc
• Designed granular Visio diagrams to show the flow of events, as well as BPM documents for benefit of offshore developers
• Worked with developers in debugging efforts for mobile application and tracked defect in TFS
• Created wireframes using MS Visio based on collaboration with use cases and navigation flows and activity diagrams.
• Worked with different implementation partners like CGI and Deloitte and handled knowledge transfers sessions from CMS regtap.info webinars.
• Involved in FACET configuration, Customization, reporting, analysis and enhancement. Extensively worked on EDI transaction like 837, 835,834, 820, 270, 271, 276, 277 and 278.
• Analyzed business Processes, Subscribers - group - plan - county structure, current processes, Facets configurations and FACETS backend processes.
• Involved in gathering requirements, configuration, and data conversion of the Facets application modules like Enrollment, and Claim
• Configure different applications of Facets such as, Individual user set up, Group set up, Process Control Agent and Duplicate claim rule application on Medicare application, ICD Procedure codes, MDC Codes on Application Support Application.
• Collaborated with different aspects of the project, such as worker portal, individual portal, CSR portal to data integrity
• Worked on creating a new linked provider directory and patient record locator service that allows for effective handoff between clinical and administrative exchanges (HIX, IES and HIE) and Massachusetts Medicaid
• Worked on leveraging the MA Virtual Gateway (MVG) services for all three Massachusetts exchanges (HIX, IES and HIE).
• Worked on projects like implementation of Oracle Identity Management system (IAM) and IBM master data management.
• Solid knowledge of clients’ policies and business rules and translating them into the understandable concept to use for use case and business requirement creation
• Instrumental in introducing the different moving parts like Dell FMS methodology, a new approach to requirements gathering, software development life cycle (SDLC) process and software testing life cycle (STLC)
• Leveraged Federally facilitated Exchange (FFE) artifacts to accelerate development
• Conducted Peer Reviews on Use cases and other requirement artifacts
• Worked on Data Migration and validation testing of the new user stories and scenarios using Team Foundation Server (TFS)
• Performed User Acceptance Testing by providing, user guides, and user manual to end users

Confidential, Franklin Lakes, NJ

Business System Analyst

Responsibilities:

• Prescriber/Provider block based on 13 attributes set by Pharmacies (custom block lists)
• Detection of and processing of eligibility of benefits from a subscriber of multiple carriers with SINGLE card
• Gathered and documented business requirements, developed scope documents and maintained them in HP QC/ALM.
• Validated requirements by executing test cases for pharmacy claims, NCPDP D.0 flat file formats, loops and segments of EDI file.
• Worked to streamline work flow processes, eliminate redundant data entry, and support patient communication activities. Worked extensively with SQL Server for data mapping and data validations using complex SQL queries.
• Tested new edits introduced by the new benefits build out such as drug-to-drug interactions, duplicate therapy, and dose checking through the use of third-party database files and reported bugs on HP QC/ALM (Quality Center)
• Tested orders available for adjudication priced against pricing available from multiple third-party EDI Sources.
• Tested real-time interfaces with third-party payment processors to accept credit card and check payments from patients. Also tested manual and systematic writeoffs and adjustments to outstanding balances triggered by payment data drivers
• Tested Medical billing and performed data validations on file conversions from EDI NDC to JCODE or HCPC .
• Performed overall Requirements Management and built the Requirements Traceability Matrix using HP Quality Center /ALM.

Confidential, Louisville, KY

Facets Systems Analyst

Responsibilities:

• Identified the scope, business objective and documented the functional requirements for each release.
• Directly involved in process improvement Plans and implementing business change.
• Produced clear user manuals & guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and appropriate GUI screenshots.
• Set claims processing data for different FACETS Module.
• Conducted testing defect analysis, regression testing and working with Configuration Teams to identify and define requirements.
• Interfaces with customers and internal departments and provides support to the team.
• Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions
• Extensively worked with Member/Subscriber and HIPAA Privacy Facets application groups.
• Involved in creating documents and diagrams for Enrollment according to the HIPAA 834 Compliance Standards for Enrollment.
• Set claim processing data for different Facets Module.
• Worked on modules related to Claims, Providers, & Contracts and worked with Claims attributes, Provider attributes, enabling EOB & Remittance rules associated with Provider configuration process in Facets.
• Extracting existing claims from a target claim environment using claims tool; modifying the claims data to suit the testing scenarios for the new market
• Utilize Member module to verify eligibility, benefits and PCP assignment to maintain accuracy.
• Enrolled members through online screens and 834 Transactions to Facets.
• Modified the 834 file and then checked if the eligibility enrollment is properly loaded onto Facets.
• Processed 837P, 837I and 837D transactions, verified those 837 transactions were converted correctly to XML file format and verified the claims data loaded to Facets for further processing.
• Worked with Accumulators, Deductibles, Coordination of Benefits and Overrides of the Claim Line detail and used them for testing various claims scenarios in Facets.