SUMMARY:

• Over 7 years of experience specialized in Healthcare Claims and payments, Implementations, System Configuration, QA testing, and auditing claims for correct payment.
• Experience in SDLC, Agile, Waterfall, Rational Unified Process, and SCRUM software development methodologies.
• Proficient at coordinating with stakeholders, vendors, Subject Matter Experts (SMEs), Project Manager (PM) and end users and elicitation of requirements through Joint Application Design (JAD) sessions, Brain storming sessions, interviews, Surveys and questionnaires, Requirements workshops, document analysis, Joint Application Requirement (JAR) sessions.
• Knowledge of pharmacy data Clinical Benefit Auditing and Plan level Benefit Auditing (claims, fees, eligibility, benefits, formulary) and statistical analyses
• Expertise in Gap Analysis.
• Experienced in creating workflow analysis and design, Unified Modeling Language (UML) diagrams through MS Visio, What - IF scenario analysis (WISA), To- Be Scenario Analysis, Gap Analysis, User Interface (UI) design.
• Managing Requirement Traceability Matrix (RTM), Service Level Agreement (SLA) and assisted Project Manager.
• Strong knowledge of data mapping, data profiling, data verification, data integrity, ETL process, data dictionary, SQL queries for data analysis and data validation.
• Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.
• Extensive experience as Business Analyst in the Healthcare Industry with expertise in Affordable Care Act (ACA), HL-7, EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare and Medicaid.
• Experienced in business process flows, business process modeling, case tools, business analysis, gap analysis and organizational change management.
• Experienced in conducting sessions and worked with executives, developers, and end-users to define the exact requirements.
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS.
• Knowledge on Medicare, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, ICD-9, ICD-10, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.
• Used Microsoft SharePoint as a Web-based Content Management System as well as a Document/ Project Management tool.
• Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment).
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Medicare, Medicaid, CDHP (consumer driven health plans).
• Ability to develop business rules, context data flow diagram, entity relationship diagram, workflow diagramming, prototyping and document current state, gaps and future state processes.
• Experience in Requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.
• Comprehensive knowledge of Software Development methodologies (SDLC) such as Waterfall, Agile, Spiral and Scrum.
• Create various documents like the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS).
• Worked closely with project Stakeholders, SMEs, PM, to understand, analyze, document, validate, and review the requirements and specifications for new applications along with enhancements to the existing applications.
• Efficient in writing Business Requirement Document (BRD), Functional Specification Document (FSD), Use Cases, User Interface Specifications (UIS), System Requirement Specification (SRS) and Report Specifications Documents.
• Skilled in translating business requirements and user expectations into detailed specifications and building business process flow charts using MS Visio and Enterprise Architect to communicate project functionality to the development team employing designing techniques like OOAD and Unified Modeling Language (UML).
• Sound proficiency in analysing and creating, Use Case Diagrams, Sequence Diagram, Activity Diagram, Data Flow Diagrams, Business Flow Diagrams, Wire Frames and Mock-ups using MS Visio and Rational Rose to communicate business and functional requirements to clients and developers.
• Support the Test Team and the rest of the Development Team in compliance related issues while working with them in the development phases of the projects.
• Business Analyst with solid understanding of Business Requirements Gathering, Business Process Flow and Business Process Modelling and Data Mapping.
• Extensive working experience on Medicaid, Medicare and MMIS projects.

TECHNICAL SKILLS:

Methodologies: Agile, Waterfall

Requirement management tools: QC, Jira, Rational Requisite Pro

Project management tools: MS Project

Business Modeling: MS Visio, MS Project, MS Visio, MS Excel, MS Word, MS PowerPoint, Jira, Confluence Wiki, Kronos, office 365, QuickBase, SharePoint

Web technologies/languages: SQL, XMLFront-End tools: Microsoft Excel, Word, Power Point, SharePoint

Database & BI: MS SQL Server, Oracle, Informatica, SSIS, SSAS, SSRS

EXPERIENCE:

Business Systems Analyst

Confidential, Fort Lee, NJ

Responsibilities:

• Played an active and lead role in gathering, analyzing, and writing business requirements.
• Project was implemented in phases, enabling system to deliver as many business requirements as early as possible.
• Involved in Requirement Scoping and analysis of high priority requirements for implementation.
• Worked on Transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
• Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
• Evaluated Medicare requirements and benefits in Medicare Health Plans for member enrollment and management.
• Coordinated, implemented and provided on-going support of the Quality Performer as outlined in the Specifications Manual for Well Care Inpatient Quality Measures Centers for Medicare & Medicaid Services (CMS).
• Used HP Quality Center for writing Test plans and Test Cases.
• Working knowledge of implementing software development projects using methodologies such as Waterfall, RUP, and Agile Scrum.
• Used HIPAA guidelines and regulations to keep track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.
• Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project. Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
• Developed Software Requirement Specification (SRS) document using Visio and MS Office.
• Worked on Agile SDLC during the project phase, performed the role of Product Owner and Team member in Scrum Meetings.
• Participated in agile process - planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iteration.
• Involved in Testing Out-Bound Transactions (835 Health care claims Payment, 277 Claim Status Response).
• Consulted with healthcare third-party Administrator Company to develop conversion specifications for member, enrollment, and authorizations.
• Involved in Scrum development process and prepared Sprint burn down chart, product catalog and sprint backlog contain Business Requirements and supporting documents that contain the essential business elements and definitions as well as the tasks to be completed.
• Responded to billing inquiries from patients and payers.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/ Advice).

Business Systems Analyst

Confidential, El Paso, TX

Responsibilities:

• Act as a strategic partner between the business community and IT development teams to resolve functional and technical issues related to business applications to troubleshoot data or transaction issues and to review opportunities to leverage new functionality
• Work with clients to document functional test scenarios, test plans and end-user acceptance testing criteria.
• Identified the business functions and processes, and prepared system scope and objectives based on user needs and industry regulations.
• Defined terms conducted stakeholder analysis, elicited business needs, conducted business process modeling, and facilitated JAD sessions.
• Elicited, documented requirements and use cases. Analyzed, validated & prioritized requirements; traced requirements to related project documentation (process models, designs, test scenarios & scripts).
• Actively analyzed current business processes (Claims, Recipient eligibility and enrollment etc.) and worked with management to improve and implement enterprise solutions to ensure compliance
• Documented the Requirements and circulated them to Business & Technical teams for Signoffs.
• Maintained traceability through updates to the Requirement Traceability Matrix (RTM) using Requisite Pro.
• Identified testing scenarios and defined Test Cases for detailed functional testing.
• Facilitated claims processing while passing 837 claims for a compliance check and running through load processing.
• Developed a Schedule and identified project milestones.
• Analyzed business scenarios to track possible business outcomes for the functions which could be incorporated into more detailed test scripts.
• Reported project progress to the team, senior management and all stakeholders periodically.
• Identified risk and project impact and performed risk assessment and mitigation.

Environment: SQL, MS Word, Excel, Access, File Viewer, MS Visio, SharePoint.

Business Analyst/ Systems Analyst

Confidential, Seattle, WA

Responsibilities:

• Played an active and lead role in gathering, analyzing, and writing business requirements.
• Project was implemented in phases, enabling system to deliver as many business requirements as early as possible.
• Involved in Requirement Scoping and analysis of high priority requirements for implementation.
• Worked on Transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
• Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
• Evaluated Medicare requirements and benefits in Medicare Health Plans for member enrollment and management.
• Coordinated, implemented and provided on-going support of the Quality Performer as outlined in the Specifications Manual for Well Care Inpatient Quality Measures Centers for Medicare & Medicaid Services (CMS).
• Used HP Quality Center for writing Test plans and Test Cases.
• Worked on documenting business rules to be defined in the business rules management engine (IBM ODM).
• Implemented software development projects using methodologies such as Waterfall, RUP, and Agile Scrum.
• Used HIPAA guidelines and regulations to keep track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.
• Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project. Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
• Developed Software Requirement Specification (SRS) document using Visio and MS Office.
• Loaded the defects on to HP Quality Center and maintained a track record of the updates on the defects from the development team.
• Worked on Agile SDLC during the project phase, performed the role of Product Owner and Team member in Scrum Meetings.
• Participated in agile process - planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iteration.
• Involved in Testing Out-Bound Transactions (835 Health care claims Payment, 277 Claim Status Response).
• Consulted with healthcare third-party administrator company to develop conversion specifications for member, enrollment, and authorizations.
• Involved in Scrum development process and prepared Sprint burn down chart, product catalog and sprint backlog contain Business Requirements and supporting documents that contain the essential business elements and definitions as well as the tasks to be completed.
• Responded to billing inquiries from patients and payers.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/ Advice).

Business Analyst

Confidential, Brunswick, ME

Responsibilities:

• Facilitated meetings with the team for Requirements Gathering.
• Created Data Dictionary for data migration.
• Acted as a primary liaison between business lines, operations, and technical areas throughout the project cycle.
• Conducted several Requirement Gathering Sessions for gaining detailed requirements and finalizing Business
• Requirement Document (BRD).
• Created User Requirement Specifications (URS) and Functional Requirement Specifications (FRS) documents.
• Conducted JAD sessions and meetings with developers, QA team, and users for communicating primary requirements,
• Discussed different versions of requirements, queries, and clarified the issues.
• Reviewed Business Requirements Documents and the Technical Specification.
• Design UML diagrams like Use Case Diagram, Class Diagram, Sequence Diagram, and State - Diagram for project documentation using MS Visio.
• Set up definitions and process for test phases including Product test, integration test, system test and User Acceptance Test (UAT).
• Wrote SQL Queries to perform Data Validation.
• Implement business modeling using MS Visio to develop screens for the application.
• Extensively used MS-Office and SQL Queries for data handling
• Ensured that project followed Business Rules and was compliant with HIPAA rules to display minimum benefit information.
• Extensive use of MS Project to maintain record of recommendations, communications, activities, schedules and to monitor progress of project in real time.
• Used Rational Rose and UML to produce use case models, and sequence diagrams, as part of the detailed design of interfaces.
• Established strategic partnerships with the business units to develop a solid understanding of the business line; including the business plan, products, and process and revenue streams.
• Involved in defect tracking and bug management using Rational Clear Quest.
• Planned, scheduled, and controlled projects based on plans and requirements outlined by the business.

Environment: Rational Rose, UML, SQL Queries, QC, SharePoint 2007, Oracle 9i, MS Word, MS Excel, MS Office, MS Visio, MS Project, Windows XP