PROFESSIONAL SUMMARY:

• Over 20 years of IT Experience with an emphasis on Business & System Analysis, Software Testing End to end, and Maintenance including 7 years of Operational experience in EDI application support.
• Proficient in Agile and Waterfall Methodologies.
• Certified Scrum Master (CSM) through Scrum Alliance
• Expertise on Legacy systems, Client - Server and Web Applications.
• Extensive Experience in Commercial & MEDICAID Health care arena in following areas Fiscal Intermediary Shared Systems (FISS) Claims Processing, Common Edit Module (CEM) Front end edit processing including all HIPAA Transactions.
• Requirement's gathering with extensive analysis for both mid-scale to large scale system development projects. (Including but not limited to Gateway Reengineering).
• Proficient skills and knowledge related to testing (System & Integration Testing, Regression Testing, UAT, Functional Testing and Volume Testing, Creation and execution of test matrix for both internal and external users).
• Extensive experience in EDIFECS/Specbuilder, Cognos, Informatica, Infosys CMS, FTP SFTP, Mercator, Amisys, Pro32, Quality Center (QC), SQL query Management Practice Systems (MPS), GP.Net, TSOG (IBM Mainframe applications).
• Proficient experience in handling On-Call support production support.
• Extensive knowledge of HIPAA Standards and Security.
• Extensive knowledge of 5010, ICD-10, Centers for Medicare Medicaid Health Benefit Exchange.
• Proficient experience with interacting with trading partners and creating standard specifications for various inbound and outbound transactions using ANSI X12 4010 and 5010 standards.
• Extensive experience in EDI transactions 837I/P, 835, 834, 820, 278, 270/271, 276/277, 999A/E, 277CA & TA 1.
• Experienced in Data Analysis Techniques & Data Management Tools (MS Excel, SQL & Relational Databases)
• Excellent root cause analysis, advised options, risks, cost benefit analysis and impact on other business processes and system priorities to clarify interdependencies, to ensure systems traceability of projects are accurate.
• Experience with CAQH
• Strong analysis, coding and design skills.
• Excellent documentation and PowerPoint presentation skills
• Highly advanced written and oral interpersonal communication skills, PC skills and problem-solving skills.
• Over 15 years of consistent, excellent Customer Service/ Advocate Skills
• Proficient experience as Client management liaison for Provider Services, Provider Contracting and Reimbursement, Project management functions, managing multiple projects simultaneously and working with Developers / Testers via onsite and or offshore business models.

PROJECT EXPERIENCE

Confidential

Sr Business Analyst

Responsibilities:

• Gathering Requirements for CMS updates
• Facilitating JAD/JRP sessions for internal customers
• Troubleshooting errors for RAPS/EDPS and Revenue Reconciliation product lines of business.
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Troubleshooting test and production issues for EDI and proprietary transactions including but not limited to Encounters product sweeps (999, 277, MA02-MA04)
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Review current manual process to automate by replacing manual touch points with job scripting and scheduling.

Confidential

Sr. Core System Business Analyst

Responsibilities:

• Troubleshooting core system (IDX) errors for Business Units (Claims, Benefits, Medical Management, Pharmacy)
• Testing specs for the systems that interface with IDX
• Modification, Updating, Adding Creating Rules for Rule Banks
• Modification, Updating, Adding Creating various Dictionaries
• Facilitating meetings with both internal/external customers
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Review current manual process to automate by replacing manual touch points with job scripting and scheduling.
• Support business critical projects through the system development life cycle
• Modify and maintain rulebanks for IDX (GE Centricity)
• Maintain Dictionaries (Provider. Employer)
• Implementation of New Document Generation Solution (Napersoft)

Confidential

Sr. EDI & SharePoint Programmer Analyst

Responsibilities:

• Troubleshooting test and production issues for EDI and proprietary transactions
• Point of contact for Centers of Medicare/Medicaid (CMS) regarding the Edge Server
• Attend weekly CMS Edge server calls and work groups, communicating to upper management any issues that may require action
• Responsible for all Preferred Provider Group (PPG) onboarding and testing
• Requirements gathering for both internal and external customers relating to service requests
• Managed communications between application users and vendors reporting to provider representative as needed
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Review current manual process to automate by replacing manual touch points with job scripting and scheduling.
• Support business critical projects through the system development life cycle
• Remediate EDI processes to send and receive X12 file formats which contain ICD10 codes by the compliance date 10/1/15. Complete testing with inbound and outbound trading partners. Support the enterprise ICD10 project

Confidential

Sr. Enrollment Accounting EMPO Business Analyst

Responsibilities:

• Create Business Requirement Documents (BRD's)specific to Medicaid/Medicare 834 (Enrollment)
• Create and update Test Case Scenarios specific to Market Place Exchange for several states including but not limited to OH, FL,MI,
• Gather and document Business requirements specific Subject matter Expert for Enrollment projects
• Facilitated project review walkthroughs
• Identified interfaces that need to be standardized and consolidated with timeline (immediate, future).
• Participated in weekly conference calls with corporate Business Intelligence team to improve reporting functions
• Gathered all impacted HL7 field information of each applications in to Impact Analysis document.
• Tested the Business test case scenarios specific to 834 transactions.
• Prepared GAP analysis, impact analysis, migration documents of the assigned application.
• Collected purchase orders from applications to help remediate all project related activities and submitted it to the legal team for approval.
• Managed communications between application users and vendor and contacted application vendor as needed.
• Raised change request and participated in Change Management as required (To perform testing on the production).

Confidential

Senior EDI HIPAA 5010 CEM FISS Business Analyst

Responsibilities:

• Interpretation of CMS guidelines, mandates and quarterly updates for front end edits
• Subject Matter Expert for Common Edit Module (CEM)
• Analyze Medicare/ Medicaid requirements to effectively create ANSI 5010 transaction.
• Gathering business requirements, per CMS change requests for 837 I/P, 276/ CA
• Create test case scenarios that meet CMS guidelines as swell as creating fixes for code when issues arise.
• Troubleshooting CEM edit issues to resolution.
• Review and monitoring of test cases with in Quality Center.
• Review CMS requirements on a daily basis, including but no limited to monitoring ECHIMP for updates, changes, modifications to CR's (Change Requests).
• Participate in EIC or 3 and 5 day sessions, system related walkthroughs inquiring, documenting questions providing comments as needed.
• Determine appropriate level of testing needed for each CR.
• Perform CR analysis necessary to develop accurate, testable test scenarios.
• Develop and maintain High quality Test Scenarios within Quality Center.
• Work closely with seasoned testers for developing the detailed Test Procedures and Test Case Specifications.
• Develop and maintain test documentation including Test Scenario Specification, Test Plan, and Test Case Specification.
• Conduct BA/Tester meetings with Testers to present the test scenarios and answer questions.
• Support defect management life cycle resulting no unresolved issues before implementation.
• Attend (facilitate within STCCEM) POC review twice weekly including analysis and research of and distribution of POC drafts among delegated team members.
• Contribute towards internal Software Quality Assurance Processes.

Environment: FISS production and beta testing, Soap UI, Quality Center, Sharepoint, .

Confidential, New Jersey

EDI Business Analyst HI & SME

Responsibilities:

• Subject Matter Expert for 270/271 transactions
• Subject Matter Expert for 275 Attachments
• Served as member of the Executive EEI4 Core team for Horizon
• Documented and maintained MTM, Internal Audit, Gateway Modernization
• Reviewing test case scenarios, creating UAT test cases, P2P testing, Global Testing
• Cognos reporting, Dx Console, Informatica, Infosys onshore/offshore
• Assisted business analysts to perform business impact assessment, gap analysis and documenting functional design documentation during EDI gateway platform conversion.
• Created 4010/5010 cross walk to identify gap analysis for mapping of Detailed Design Documents, Data Models, Screens Layouts and Reports,
• Serving as Subject Matter Expert to identify impacts, analyze issues & drive solutions for 270/271 Eligibility and response real time transactions during gateway conversion.
• Perform business process redesign and documentation as needed for gateway modernization from mainframe to websphere platform.
• Contributed to the development of a process and approach to use of Biztalk mapping and code remediation.
• Perform project management activities, support development of test scenarios / cases & the execution of testing activities.
• Establish credibility at all levels within the client and build problem-solving partnerships with the clients and colleagues.
• Proficient with SQL Language, including but not limited to writing SQL queries to troubleshoot and resolve issues related to Managed care .

Environment: SQL, EDIFECS Code Management System, Informatica, Biztalk, MS-VISIO.

Confidential, South Carolina

Sr. Commercial Client Advocate/EDI Business Analyst

Responsibilities:

• Provide EDI support to all internal departments (Claims -FFS & Encounter) and all external trading partners.
• Work with internal and external trading partners in eliciting EDI business requirements due to growing business needs..
• Perform Mapping; (Validation & Translation) both on Inbound 837 I/P & for Outbound 835 ERA.
• Build an d maintained internal Partner Relationships by identifying problems and following through to resolution in all EDI transaction aspects.
• Maintained HIPAA transaction maps, and code lists to enhance seamless processing of transactions both inbound and outbound including CARC and RARC code updates or 835 ERA to providers & Trading Partners.
• Researched all production issues for the designated clients of the IT department.
• Advised options, risks, cost benefit analysis and impact on other business processes and system priorities to upper management.
• Coordinated multi-system solutions to clarify interdependencies, to ensure systems appear seamless to customers.
• Gathered business requirements, prepared and submitted work definition documents.
• Performed business systems analysis, across multiple platforms including Managed care.
• Developed and implemented an automated 835 ERA process control schedule to ensure data transfer within a timely manner to prevent delay of 835ERA remit processing.
• Provided regular communication of all assigned projects to Executive management, held JRPS (joint requirement planning sessions), with members of the various project teams and their project managers to ensure projects were on track without scope creep and implemented on time.
• Worked with Transactions Healthcare Claims (837) & Remittance Option Information (835).
• Extensively involved in preparing COMPLIANT 8371, 837P & 835 transactions.
• Worked with EDI/ANSI X12 environment.
• Involved in building Test cases, Test scripts, and Test plan documents for testing EDI gateway.
• Prepared Test cases, Test scripts, Test plan documents for testing new repository for HIPAA 5010.

Environment: NASCO, CICS, TSO, MS-VISIO, CLAREDI, FTP/SFTP, Amisys

Confidential, Denver, CO

EDI/EC Business Analyst

Responsibilities:

• Researched and resolved Health Insurance Portability Accountability Act ( HIPAA) compliant electronic claim files.
• Prepared test scripts for production and user acceptance test environments. Performed issue resolution of all ANSI HIPAA x12 transactions, 401098A1, 401091A1, 401096A1, 276/277, 270/271, 278.
• Performed Quality Assurance and escalation of EDI services to Management as needed. Customer Advocate/Member and Provider Appeals
• Facilitated meetings and orientations providing status and progress reports to acquire and disseminate business and technical knowledge for the Provider Community.
• Resolved complaints and appeals for all lines of business to ensure compliance with government and regulatory entities. Including, ensuring that NCQA guidelines were in compliance to avoid fines and other financial penalties.
• Answered incoming calls for the State Dedicated Employees, for both Providers and Members, escalated and resolved senior representative calls as needed.