SUMMARY

• Senior EDI Analyst/Business Analyst with years of industry experience and expertise in Business Requirement gathering, Business Process flow, Business Process Modeling and Business Analysis in Healthcare, Strong at writing skills in preparing Business Requirement Documents (BRD), System Requirement Specifications (SRS), Software Requirement Specifications (SRS), Use Case Specifications, Functional Specifications (FSD), Requirement Traceability Matrix (RTM) and Technical Design Document (TDD).Strong at Data Analysis, Data Mining, Data Mapping, Data Quality and Data Profiling.
• In - depth knowledge of Pharmaceutical & Medical and Healthcare organization operations including outsourced operations, Health Insurance, Procedural and Diagnostic codes and Claim s Process HIPAA, and Medicare/Medicaid/MMIS, including MITA.
• Strong knowledge and understanding of NCQA/ MACRA/MIPS requirements, conduct training Medicare wellness (AVS) & EPIC Healthy Planet reporting. Experience of Patient Protection and Affordable Care Act (PPACA).
• Experience of Medicaid Information Technology Architecture (MITA).Experience Software Development Life Cycle (SDLC) phases such as Planning, Analysis/Design, Development, Application lifecycle management (ALM)and Testing for the software/system development processes.
• Experience with prototyping in Cognos and dashboards in tableau. Experience in creating and executing test plans for functional tests,QA tests, regression tests, smoke tests and UAT using TestLink .
• Understanding of Pharma regulatory, Risk and compliance operations along with R&D .Working experience of EDI 4010 & 5010 . Expertise in testing the process by tool JIRA . Well versed in project management tools like MS-Project, Team Foundation Server (TFS), and Liquid Planner for status reporting, scheduling and planning.
• Expertise in creating mockups using Balsamiq . Extensively used rational tools for UML, tracking and reporting and applied the Rational Unified Process in all areas of a software development life cycle.
• Good at Conducting JAD sessions, creating Use Cases, work flows, screen shots and Power Point presentations for the Web Applications, SQL scripts and SQL Server Data warehouse systems. Extensively worked on all phases of Data Warehousing project like Data Cleansing, Data modeling for data staging & Data Mart, ETL, Indexing, Quality Assurance, Data updating plan, and Data presentation to business users .
• Strong at loading (ETL) process using SQL scripts .Well versed in project management tools like MS-Project for status reporting and planning. Expert in conducting business reviews, walkthrough sessions and facilitated monthly and weekly meetings/reviews. Expert in coordinating work plan between project manager and the client with Microsoft Project

AREAS OF EXPERTISE

• EDI X12 / HIPAA standards
• EDI Mapping and Development
• EDI Implementation and Support
• EDI Administrator and Analyst
• Requirements Documentation
• Software Quality Assurance
• EDI Data Analysis
• User Training Interfacing with multiple departments
• Internal and External Communications
• Multiple EDI Translators
• Application Configuration
• Application Deployment
• Microsoft SQL Server

TECHNICAL SKILLS

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2, Teradata

Reporting Tools: Crystal Reports

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite (Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes, Cognos.

Performance Testing Tools: Virtual User Generator, Load Runner

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

PROFESSIONAL EXPERIENCE

Confidential

Sr. EDI Analyst

Responsibilities:

• Assisted in modeling and documenting the end-user's AS-IS workflow and TO-BE business processes.
• Monitored EDI inbound/outbound traffic flows, reviewed error logs, and resolved any errors related to data processing.
• Gathered Business Requirements from SME's and drafted Business Requirement Document (BRD) and presented for approval.
• Started out the project in its planning phase using the Agile methodology and facilitated a weekend long meeting with the client and the team to collect business user stories.
• Performed Data Analysis and Data validation by writing SQL queries against the database.
• Analyzed requirements for developing a crosswalk for understanding major changes from ICD-9 to ICD-10 with the help of SME's.
• Responsible for implementing payers onto the Health Care Exchange (HIX) for the Affordable Care Act.
• Worked within project team to identify and interpret state Medicaid policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Queried Oracle database using SQL to find and correct errors in Business Object reports.
• Involved in HIPAA/EDI Medical Claims Analysis, Design, Implementation and Documentation.
• Developed and reported progress metrics.
• Create complex reports to track Medicaid and CHIP enrollments and spending.
• Analyzed Medicaid Eligibility Determination System for Children's Health Insurance Program (CHIP) and enrollment transaction 834 submitted to program administrator for HIPAA 5010.
• Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277). Responsible for the development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837 and 5010.
• Involved in Business Process Modeling and developing Business Requirements (BRD), Design process and providing Knowledge Transfer to the Support Teams.
• Ensure compliance with applicable healthcare claim standards and regulations through infrastructure, process controls/improvements, validations, and process design and development.
• Serving as a liaison for Medicare, attorneys and their clients, verifying confidential information.
• Used UML to create sequence and use case diagram in Microsoft Visio. Involved in MSP Mandatory Reporting Process.
• Compile, validate and report system-wide metrics to attest meaningful use of EHR to the Centers for Medicare and Medicaid Services.
• Responsible for resolving incidents and closing the defects related to EDI mapping issues during development and testing. Also, facilitate Root Cause Analysis of the issues.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI x12 Transaction, Code set and Identifier aspects of HIPAA.
• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams and Entity-Relational (ER) Diagrams in MS Visio.
• Developed Business and work Flow Diagrams, Dataflow diagrams, Activity diagrams and Use cases diagrams using MS Visio.
• Performed GAP Analysis for HIPAA 4010 and 5010 transactions.
• Assisting in writing efficient and effective Test Plans, Test Strategy, System testing, End-to-End testing and User Acceptance testing.
• Assisting business users in defining UAT test cases and plans; Established and maintained test cases and test data in Quality Center.
• Coordinated with the QA Team for testing activities across multiple systems and managed Conversion test execution.
• Involved in setting up of the records of MSP Claims Investigation into the database and performed system analysis.
• Recommend changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Monitored the compliance mapping of transactions to the EDI transactions standards ANSI -X12.
• Recommend tactic to implement HIPAA 4010 (EDI X12 837,834,278,270) in the new System.
• Do data analysis for various version changes of EDI messages on different sub-systems. Providing the required test data for the developers in order to fix the defects.
• Participating in QA team meeting and bug tracking meetings. Maintained documents and collaborated with the team by extensive use of SharePoint.

Confidential, Saint Paul, MN

Business Analyst/EDI Analyst

Responsibilities:

• Reviewed business user stories and created several Excel and Word files to document the business process, user stories and algorithm required for Iteration 1.
• Assisted in the capture and win process for the MIPs Healthcare program with CMS.
• Development of EDI maps and unit testing in EDI tool.
• Define business requirements and business process and policy changes related to the client Medicaid system during the conversion from the existing HIPAA 4010A formats to the future HIPAA 5010A format.
• Involved in writing SQL Queries using TOAD.
• Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, implementation and testing for processing of Medicare, Medicaid and Tri-care claims.
• Involved in Data Analysis, Data Mapping and Data Modeling and Performed data integrity, Data Portability testing by executing SQL statements.
• Used Requisite Pro to organize and analyze the Business Requirements. Gathered the Business requirements & converted them into Business Requirement Documents (BRD).
• Engaged in the health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS and EDI.
• Created EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors.
• Provided client documentation, advice and training for all EHR Incentive Program and other government programs updates
• Involved in GAP analysis around the identification of design rules and System Process Flows, User administration and requirements.
• Adhered data transition of the payment and remittance advice as per the EDI standard 835.
• Designed the conceptual data model and worked with the Business analysts and technical teams to design and update the logical data model in various iterations.
• Designed Test Plans and Test Cases for User Acceptance testing (UAT) with the help of QA teams.
• Worked with the management for improving and giving new ideas for designing future processes of the HIPPA transactions dealing out with EDI’S 271, 276 and 270, 470, 835, 837, 834, HIPAA 4010, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles and also well versed with ICD10.
• Created a Business Rules Document (BRD) highlighting Functional, Non Functional and Security Requirements along with Business Rules tables and Decision Tables.
• In depth knowledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors
• Conformed to HIPAA for Claims processing during Electronic Data Interchange (EDI) i.e. 834 (Benefit Enrollment), 835 (Claims Payment) and 837 (Claims Encounters) and CMS MIPS.
• Provide subject matter expertise in healthcare claims processing and utilization management processes.
• Developed use cases, activity diagrams and sequence diagrams for a clear understanding of the vision document.
• Conducted Joint Application Development (JAD) sessions with stakeholders throughout SDLC to resolve open issues.
• Wrote SQL Queries in MS Access to sort data and analyze the large set of data during project life cycle.
• Used Rational Clear Quest for defects and bug testing.
• Extensively worked in all phases of Software Development Life Cycle (SDLC) Agile deliverables using .Net framework V3.5.
• Document analysis and represented them in Requirements Traceability Matrix (RTM) using Requisite Pro. Developed use cases for Story boarding and wireframes for Interfacing.
• Made Screen Mockups/Definitions and Dependencies using Excel and Documented the Requirements
• Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagrams using Rational Rose so that developers and other stakeholders can understand the business process.
• Gathered user and business requirements through open-ended discussions, prototyping visuals and observation of the compliance department and work environment.
• Involved in the development of a Project Plan in conjunction to the Business and IT areas.
• Responsible for organizing the Quality Analyst (QA) walk through to explain proposed changes.

Confidential, Dublin, OH

Business Analyst/EDI Analyst

Responsibilities:

• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD. Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Conducted EDI map analysis to reduce errors in EDI transaction processing.
• Worked with scrum master to break the requirements into user's stories and sprints.
• Closely worked with data analyst team in defining sources and content for the data ware house component. Work on the integration of data from various sources, created comprehensive data mapping and dataflow diagrams.
• Actively participated in weekly meetings and ad hocks meetings with PM, stakeholders and delivery mangers throughout the life cycle to identify and track project issues and risks.
• Participated in JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met and interacted with technical leaders from various departments (Drug Design and Discovery-R&D division, Clinical trials etc)
• Organized meetings to Review HL7 requirements for interfaces with various third-party software applications.
• Created and maintained Service Level Agreements (SLA's) and wrote business rules pertaining to the HIX project.
• Created use cases diagrams and business process workflows using Visio
• Implemented various EDI transactions like enrollment (834) and premium payment (820) to support HIPAA transaction set.
• Got a great exposure to Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems.
• Worked with the UAT and QA teams to conduct an assessment and determine how effective UAT and QA guidelines can help the company achieve timely completion of projects.
• Effectively elaborated the Current process and gave a clear picture of the proposed process for the projects in the organization. Worked aggressively towards timely completion of High Priority Tasks.
• Participation in a HP Quality Center for System Integration Testing support and help finalizing defects.
• Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Worked with IT to resolve issues and clarify Business Requirements from the Business Owners.
• Wrote test cases, test script and test plan for testing.
• Documented the UAT Test Plan for the project and worked with the UAT team to ensure every acceptance criteria for the requirements that has been included in the UAT task plan.
• Maintained the Traceability Matrix table to uniquely trace the identified business requirements from general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked.

Confidential, Charlotte, NC

Business Analyst

Responsibilities:

• Analyzed the available artifacts such as BRDS, both functional and nonfunctional, Use cases, Content Data Flow Diagrams.
• Retrieved Data using SQL queries and did Data Mapping and Data Analysis.
• Executed and validated data mapping for Claims via EDI into RDC through Oracle PL/SQL.
• Implemented the SDLC for the developing life cycle and followed the standards process in the application.
• Analyzed EDI maps, providing suggestions for map development to reduce errors in EDI transaction processing.
• Analyzing the requirement documents and preparing the entity relational diagram.
• Translated business requirements into functional requirements and approaches for developers.
• Provided management support to the offshore End-to-End integration/ Regression Test Team.
• Analyzed corporate healthcare business processes to develop customized solutions.
• Working with Medicare operational management to monitor, trend and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Worked on MS Visio to design and create Process Flow Charts, Activity diagrams with Swim Lanes, Data Flow Diagrams and Use Case Diagrams.
• Interacted with healthcare clients to gather requirements, objectives, and input and output requirements.
• Developed test cases and scripts for front end testing.
• Performed execution of test cases manually to verify expected results.
• Ensured the accuracy and consistency of the data during the data loading process.
• Developed Use case, Functional, Object diagrams using Rational Rose.
• Responsible for architecting Medicare solutions.
• Actively involved in functional and UAT phase.
• Developed a detailed test plan and test cases to cover all the requirements.
• Created design document UML diagrams and Microsoft Visio.
• Developed Flowchart and process diagram using Microsoft Visio.
• Analyzed data architecture, documented and delivered data mapping, performed risk analysis.
• Conducted walkthroughs with the end users and stakeholders to gather the modification requests from the user to upgrade or change the business specifications for the product and ensured that the developers were updated.
• Conducting Review Requirements meetings to identify missing or incomplete requirements and to identify potential test cases.
• Performed requirements modeling and develop analysis diagrams, activity diagrams, sequence diagrams, state diagrams, data models, and use-case realizations using RUP tools in Agile.
• Created and maintained a project schedule using MS Project showing all of the deliverables target dates.
• Maintained a requirements traceability matrix in order to keep the clients and all the teams up-to-date with the current progress of the project.