PROFESSIONAL SUMMARY:

• 6+ years of Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollment and eligibility processes.
• Good functional knowledge of HIPAA regulations, ANSI X12vstandards& working knowledge of HL-7 message standards, support and maintenance.
• Complete knowledge of registration, scheduling and billing processes for Revenue Cycle and Patient flow.
• Excellent knowledge of E-Commerce, healthcare IT along with HIPAA regulations, EDI transaction Code Sets, and CMS regulations.
• 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.
• 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.
• Excellent verbal and written communication skills with interpersonal and analytical skills
• Demonstrated ability to adapt into new environments, learn new skills and participate/lead teams.
• Creative and aggressive self-starter and a versatile team player with excellent analytical, problem-solving capability for collecting clear and detailed Business Requirements and Functional Specifications.
• Team player, hardworking, highly self-motivated, fast-learner and goal-oriented individual committed in pursuing a long-term career in Information and Communication Technology.

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

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

Testing tools: Rational Robot, Rational Clear Quest Test Manager, HP Quality Centre, Quick Test Professional (QTP), Load Runner, Win Runner Apps & Webservers Apache web server, Tomcat, IIS.

PROFESSIONAL EXPERIENCE:

Confidential, Columbus, OH

Senior Business Analyst

Responsibilities:

• Experience with Healthcare systems like FACTES in various areas like Enrolment, Customer Service, Billing and Network X Pricing
• Good knowledge of Health Plans managed care concepts (Medicaid and Medicare) and experienced in determining the eligibility, billing experience within life and Disability claims in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Adept with different methodologies which include Agile, Waterfall and Rational Unified Process (RUP)
• Well versed in Requirement Gathering through techniques such as JAD sessions, Interviews, Document analysis and Reviews
• Expertise in documenting Business requirement document (BRD), Functional and Non-functional requirements, Requirement Traceability matrix (RTM), Use case Specifications and the complete System Requirement Specifications (SRS)
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions (837, 835, 276/277, 270/271)
• Creation of Gap/Impact Analysis and Operational Analysis Document for Medicaid Subrogation. Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System.
• Participated in frequent agile team meetings (Scrum planning, daily stand-ups, retrospectives) to provide guidance to an agile product development process.
• Expert in Tracking and Managing the Requirements using Requirement Traceability Matrix (RTM) that controls numerous artefacts produced by the teams across the deliverables for a project
• Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
• Involved in meetings for Test Planning, Test Preparation, Test Execution and Issue Resolution and Report Generation to ensure that all aspects of a Project are in Compliance with the Business Requirements.
• 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.
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Reviewed Test plans to make sure all the requirements have been covered and corresponding test cases have been created
• Excellent analytical & problem solving skills and a team player with strong interpersonal and communication proficiency
• Interface with clients from Operations, Marketing, Sales, Technologies, and Outside Vendors and act as their customer interface point as the lead of the Projects
• Highly motivated team player with excellent Interpersonal and Customer Relational Skills, Proven Communication, Organizational, Analytical, Presentation Skills, and Leadership Qualities.

Environment: EDI, HIPAA, Windows NT, UML, Facets Trizetto, ERWIN 4.0, SQL, Rational Requisite Pro, MS Project, MS Office Suite.

Confidential, Albuquerque, NM

Business 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 (, 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 / / 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.
• 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.
• 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.
• 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.

Confidential, Groton, CT

Business Analyst

Responsibilities:

• Understood and articulated business requirements from user interviews and then converted requirements into system requirements.
• Designed and developed business flow diagrams, wireframes, mock ups, user interface design, activity diagrams, sequence diagrams, Object Oriented models using MS Visio.
• Conducted JAD sessions with end user community ensuring that the software addressed all business needs, analysis of the potential users of the system either through discussion.
• Clarified client requirements, business needs and project objectives, via feedback sessions and client meetings, in collaboration with all stakeholders.
• Collaborated with Sales and Marketing teams, external ad agencies, third-party technology distributors to facilitate communication for successful project launches.
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Assisted Design Team in preparing SSR, Software Design Document (SDD), User Interface Design, Application Architecture and Database Modeling
• Create, develop and manage content for organization's web presence (requires working with content management software).
• Responsible for weekly conference call reviewing the progress, issues, bottlenecks and any technology constraints.
• Worked extensively with the Data Modeler and Technical Project Manager to draft the Logical Data Model.
• Performed Defect Tracking and Project Tracking using Jira - Change Notification Request (CNR).
• 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 opportunity for other team members.
• Extensive work experience in analyzing the data from various sources in data warehousing/ mining environment; analyze and determine the gaps; hands-on experience in designing the ETL processes/ procedures.
• Hand on work experience in writing Excel complex macros to pull data from various sources to mine the information; as a lead helped, reviewed, hand held the programmers in writing the macros; helped the QA testers in writing the macros during the system test phase.
• Designed all the online screens with mockup diagrams and also designed all the reports for the look and feel
• To work in the Scrum team and participate in backlog review and sprint planning sessions while following the agile methodology.
• Responsible for integrating with Facets .Designing test scripts for testing of Claims in Development, Integration and production environment.
• To analyze and resolve the ongoing issues with the Data Warehouse and the ETL processes/ upstream and downstream applications.
• Strategized project scoping and specifications documents, logical data model, to clearly communicate the project roadmap.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables
• Met with all developers, offshore team and project stakeholders to lead a kickoff meeting. Defined and introduced the project, team members' roles, and key deliverables. Mapped out timelines, milestones, communication processes, question and answer session.
• Generated excitement and buy-in to secure commitment to project objectives, and shared a group vision to start the team on a motivated track

Environment: MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio, BIE), MS-Project, Windows 2000, OBIEE, Business Objects, SharePoint, Epic, Adobe CS3, Microsoft EDW, MS SharePoint, Six Sigma, .Net 4.0, RUP, Agile, SDLC, TFS, Microsoft Test Manager, People Soft.

Confidential, PA

Business Analyst

Responsibilities:

• Writing the detailed user needs, Gathered business, functional requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD (Object Oriented Design) using UML and Visio.
• Identified, researched, investigated, analyzed, defined and documented business process and Use Case scenarios.
• Conduct workflow, process diagram and GAP analysis to derive requirements for existing systems enhancements.
• Experienced in software development life cycle such as Waterfall, Agile-SCRUM methodologies, Business Analysis and Modelling.
• Instructed and modeled core Agile principles of collaboration, prioritization, team accountability and visibility, ensured consistent application of SCRUM methodologies across the enterprise.
• Led JAD sessions with stakeholders to analyze system needs and integrate requirement to develop a consistent navigation structure
• Helped manage risk analysis and mitigation plans, status reports, and client presentations; prepared business process models, defined milestone deliverables, and established critical success factors.
• To draft the Business Information Requirements documents according to standard templates, and then collaborate with stakeholders/SME's to validate those requirements and to obtain a signoffs on the documents.
• Implementing software development methodology for designing and building multi-user software applications that administer Mental Health benefits for 3.75 million insured participants, researched EDI for use in Eligibility tracking.
• To develop and deliver a comprehensive Project Plan with milestones and specific tasks for each of the stake holders and IT resources. Drafted the Functional and Technical Specifications; the high level business and user requirements decomposed into functional attributes, external interfaces, constraints, system and technical requirements for the Operational reports.
• Medicare Coordination of Benefits is the process for ensuring that payment of Medicare beneficiaries’ claims is properly shared among insurers when the beneficiary is covered by private insurance in addition to Medicare. By coordinating benefits, the COBC assists Medicare in paying claims more accurately the first time, which saves costly follow up and mistaken payments.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence).
• Functioned as a business liaison to the Design and Development teams during translation of requirements specifications into software solution; reviewed the detailed specifications, unit tested the system, worked closely with the QA team during system and integration testing.
• To function as the coordinator for the project involving the conversion/sell over of members from legacy system to Facets.
• Responsible for all the Project Management activities like effort estimation, task allocation, issue resolution, escalation to senior management, participation in the monthly steering committee meetings and to hold post launch review meetings
• Got exposure of IBM mainframe environment for Medicaid Management Information System impact assessment. Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider
• Functioned as the primary liaison between the business line, operations, and the technical areas throughout the project cycle.
• Analyzed research on operational procedures and methods and recommended changes for improvement - with an emphasis on automation and efficiency.
• Assist with user testing of systems, developing and maintaining quality procedures, and ensuring that appropriate documentation is in place.
• Develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.

Environment: RUP, MS Project, ANSI X12 - EDI, Rational Rose, HP Service Desk, MS Visio, MS Word, MS Excel, Medicare, Medicaid, Rational Requisite Pro, SQL..