PROFESSIONAL SUMMARY:

• Business Systems Analyst with 7+ years of experience in business process analysis/modeling, business requirements gathering, database design and development.
• Good Knowledge of software development methodologies (Waterfall and Agile) including client interaction, requirements gathering, analysis and tele - conferencing with the client during the progress of the project.
• Consistent experience in the following areas: Ability to Elicit, Analyze, Gather and Document Business Requirements, and experienced in writing Use Cases.
• Extensive experience in gathering business requirements, business processes, identifying risks, GAP analysis and UML modeling including Use Cases, Sequence, State and Activity Diagrams using tools such as Microsoft Visio.
• Experience with Business Reporting Tools such as Crystal Reports, Excel.
• Experience in writing SQL queries and optimizing the queries in Sybase, Oracle and SQL Server
• Experience in creating and maintaining the Requirements definition documents that included Business requirements and Functional requirements.
• Experienced in conducting Requirement Analysis, Use Case Design, Designing Test Plans and developed database schemas based on the logical models.
• Excellent skills of developing Use Case diagrams, Sequence diagrams, State Chart diagrams, and Class diagrams.
• Working knowledge of UAT, including documenting SME needs, conducting training to smooth out the user experience when onboarding upgraded systems
• Experience in using Joint Requirement Planning (JRP) and Joint Application Deployment (JAD) sessions for gathering requirements and elicitation.
• Highly analytical in developing the methods and measures to meet requirements and solve any issues that arise during the project
• Responsible for EDI strategies (EDI 835, 837, … 278) enabling Health Care Providers and Insurance Careers to communicate effectively.
• Medicare and Medicaid Claims processing, Membership, Eligibility Verification and knowledge of HIPAA, X12, and HL7 guidelines, and Medicaid provider best practices.
• Good knowledge of ICD10 project: ICD9 to 10 crosswalks, gap analysis, worked on mapping the ICD 10 codes.
• Good Knowledge on HIPAA … versions, Regulations, ICD 9/10, Facets and Claim Processing.
• Skilled in track environment build release level at various point in the software building process
• Proficient in writing SQL queries and in creating complex SQL Queries using Joins and Sub-Queries

TECHNICAL SKILLS:

Operating Systems: Windows 10

Testing tools: ALM, Quality Center, Helix-ALM

Database: MS SQL Server, Oracle, MS Access

Other Tools/ Applications: Tableau, Weka

Methodologies: UML, RAD, RUP, JAD, Agile, Waterfall

Other tools: MS Visio, Balsamiq, Smart Draw, MS Project

PROFESSIONAL EXPERIENCE:

Confidential, Buffalo, NY

Business Systems Analyst

Responsibilities:

• Generated Dashboards through the use of Power Pivot and Power View to make data more visual.
• Performed pre- and post-patch simulation at offshore to ensure the process, requirements, and solutions meet the business objectives.
• Reviewed the gaps with business & technical team. E.g. severity edits changes, new/updated code sets, HIPAA SNIP level changes, mapping changes, ICD-10 updates, etc.
• Created ETL documentation such as EDI X12 837(P,I), 834 and 835 Data Mapping, Transformation logic for Main Frame Layout, Updating Meta data documents for new Platform.
• Enhanced the Medicaid encounter (837) and enrollment (834) companion guides, enhanced requirements, co-authored test plan, and developed test data via SQL and manual editing (ETL)
• Performed validation of X-12 270, 271, 835 and 837 Professional and Institutional format files according to EDIFECS engine.
• Worked back & forth with the SQL Database & Crystal Report developing tools for manipulating the data & gathering reports
• Perform Analysis, Design, Development and Implementation of X12 EDI maps by using Ramp Manager Application (an EDIFECS Program).
• Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in EDIFECS.
• Executed EDIFECS validations for verifying the bill and claim file structure.
• Used Spec Builder to check SNIP levels of X12 files for various EDI transactions
• Set up Standard & Non-Standard Contracts in Facets, including new practitioner profiles, billing group practice numbers and provider affiliations.
• Plan documentation loading that included configuration of providers, contracts, and pricing on the FACETS system
• Scheduled batch and sessions within Informatica using Informatica scheduler and also wrote shell scripts for job scheduling.
• Corrected inbound 835 ERA data to pass SNIP levels 1 and 2 validation and created scripts to repair simple formatting errors.
• Created customized report using OLAP Tools such as Crystal Report for business use
• Validating different EDI transactions in EDIFecs Spec Builder manually and cleared all the SNIP Level Type errors in different EDI files.
• Worked with the DBA’s to tune SQL Queries to improve the overall performance of the database.
• Worked on sending vendor claims to feed the encounter data base for both Medicare and Medicaid members.
• Worked on EDI inbound and outbound encounters through HIPAA gateway. Worked on Line of Business related to States Medicaid and outbound encounters through HIPAA gateway.
• Re-engineered and captured EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Involved in creating reports for the end users using Crystal reports from the gathered requirements.
• Utilized SQL queries in Oracle SQL Developer in managing the database and assisted in making Data warehouse and doing Data profiling
• Responsible for the data management and data cleansing activities using Informatica data quality (IDQ).
• Scheduled batch and sessions within Informatica using Informatica scheduler and also wrote shell scripts for job scheduling.
• Maintaining requirements/business rules for Enterprise Data Warehouse, Business Intelligence Tools

Confidential, Tallahassee, FL

Business Systems Analyst

Responsibilities:

• Gathered and analyzed Business and System requirements with the customers.
• 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.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 835, 837 (I,P,D) and 820) standards
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions (837, 835, 276/277, 270/271)
• 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) .
• Worked on EDI inbound and outbound encounters through HIPAA gateway. Worked on Line of Business related to States Medicaid and outbound encounters through HIPAA gateway.
• Involved in claim adjudication process of facets application.
• Experienced on Facets data model.
• Engaged on the loading EDI 834-file to Facets through Membership module.
• Enhanced the Medicaid encounter (837) and enrollment (834) companion guides, enhanced requirements, co-authored test plan, and developed test data via SQL and manual editing (ETL).
• Worked on EDI inbound and outbound encounters through HIPAA gateway. Worked on Line of Business related to States Medicaid and outbound encounters through HIPAA gateway.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan).
• Able to research and resolve claim/ encounter issues, pended claims and update system as necessary
• Met with business users and stakeholders to understand the customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
• Involved in understanding the current business process, defining scope of the project along with position statement.
• Extensively worked on Managed Care Provider Enrollment.
• Responsible for creating business work flows and processes and creating management reports based on the analysis.
• Developed and executed SQL queries on claim records to validate reporting data.
• 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) .
• Worked in testing the professional, institutional claims processing and adjudication and validate data with facets.
• Used MS-Visio for model diagrams and Rational Rose for UML class modeling and Visual modeling.
• Actively participated in daily standups to announce completion of deliverables, updates and roadblocks, if any.

Confidential - Indianapolis, IN

Business Systems Analyst

Responsibilities:

• Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
• Extensively worked with FACETS Implementation, FACETS Billing, Claim Processing and Subscriber/Member module.
• Worked extensively on Business Requirements, Functional Specification, Data-Integration, Data Mapping, and Data Warehouse access using SQL and Crystal Reports, ETL process, use cases modeling (UML) using MS Office (Word, Excel, Access, Visio) and dashboards.
• Extensively worked on Design and development of SSIS (ETL) packages to extract, transform and load data from different Sources like Excel files, flat files to the Data warehouse using different tasks and transformations like File System Task, Data Flow Task, Derived Columns, and Execute SQL Task.
• Designed SSIS Packages to transfer data from various sources like Oracle, DB2, SQL Server, Excel and Access to SQL Server using Business Intelligence Development Studio.
• Designed various packages for Parallel ETL mechanism using SSIS Control flow and Data Flow components.
• Worked on EDI 834, 837, 835 and 278 files and validated the functionality according to HIPAA regulation
• Worked with eBilling and EDI HIPAA Claims (837/835/834) processing.
• Participated/facilitated Agile ceremonies including backlog grooming, sprint planning, sprint demonstrations and retrospectives.
• Analyzed the change detection process on FACETS database tables to capture the daily changes done by Users through Online FACETS Application.
• Migrated data from Heterogeneous data sources (Excel, Flat File and CSV file) to centralized SQL server database using SQL server integration services (SSIS).
• Used SSIS jobs for implementing ETL and importing data from the flat files that brings the data to the application tables.
• Used various SSIS control flow tasks such as Execute SQL task, File system task, for each loop, and sequence containers, send-mail task.
• Developed SSIS packages for ETL to migrate data from different sources including insurance groups etc to the data Involved in FACETS configuration, Customization, reporting, analysis and enhancement and also worked on membership, claim module, Batch Processing, Pricing Module.
• Created SSIS Packages by using advanced tools (i.e. pivot Transformation, Derived Columns, Condition Split, Term extraction, Aggregations, Multicasting).
• Ensures the provider, authorization and benefits configuration meets established business rules and procedures.
• Modified the provider contract, authorization rules and benefit plan configuration as required