SUMMARY

• Over 7 years of Business System Analysis experience with in - depth knowledge of Software Development Life Cycle (SDLC) and business processes in Health Care Sector.
• Strong understanding of Medicaid Management Information System (MMIS), Health Level Seven International standards (HL7), Health Care Reform, and Claims EDI.
• Working experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS) and Rapid accelerated/ anticipated Payment System (RAPS).
• Specialized experience in healthcare insurance domain including Medicare, Medicaid, PBM, Procedural Diagnostic codes and Claims Process. Profound experience with HIPAA X12EDI transaction codes such as 270/271 (inquire/response health care benefits and eligibility), 276/277 (Claim-status), 278 (Transmitting health care service information), 834 (Benefit-enrollment), 820/835 (Payment/remittance advice), 837 P/I/D (Health care claim).
• Proficient in Requirement Management, including gathering, documentation, analysis, detailing and tracking requirements mainly in health sector.
• Experienced in documenting requirement using Unified Modeling Language (Use Case and Activity Diagrams). Also building business Process Flow, Context Diagrams, Sequence Diagram, Activity Diagrams, Class Diagrams using Rational tools and Microsoft Visio.
• Expertise in Enrollment, Claims, Subscriber/Member, Plan/Product, Provider, and Billing Modules in Facets.
• Involved in Facets Output generation, Interface development and Facets Modification Projects.
• Provided analytical solution to the customers for Facets Production Issues.
• Extensive hands on experience in creating RTM, Defect Status Report, Change Request Form, Test Plan and Collaboration Diagram and designing User Interfaces (GUI) and wireframes.
• Experienced in SWOT Analysis, Gap Analysis, Risk Analysis, and Project Planning. Excellent analytical skills in understanding the business process (AS-IS and TO-BE).
• General knowledge of RDBMS, Web and SQL along with - administration, SQL Enterprise Manager, Data analysis and reporting.
• Good knowledge of SCHIP/CHIP, CMS, HMO, PPO, and POS.
• Possess a detail-oriented nature with excellent communication, interpersonal and organizational skills. Recognized for being a valued team player with ability to multi-task.
• Strong command in converting client’s non-technical requirements to precise technical representation to the team. Experienced in dealing with cross-functional team environment.

TECHNICAL SKILLS

Project Methodologies: SDLC, RUP, UML, Agile, Waterfall

Business Modelling Tools: Microsoft Visio, Rational Rose

Testing tools: Mercury Quality Center

Change Management Tools: Rational Clear Quest

Office Tools: MS Project, MS Office, MS Visio

Version Control Systems: Rational Clear Case

Database: MS SQL Server, MS Access, and Oracle

PROFESSIONAL EXPERIENCE

Confidential, OH

Business Analyst

Responsibilities:

• Using Service Now and Team Foundation Server (TFS) to link the initial regulatory and contractual obligations requirements from the business to IT.
• Create stories based on the requirements provided and broken down into smaller functional and technical specifications.
• Created Use Cases, Process Flow Diagram, Sequence Diagrams defining the ultimate ask and its processes to the business and the team to project the pain points.
• Purely working on data-warehousing side to use the available data to be utilized for various projects.
• Used SQL queries to understand the data structures and schemas available to understand architectures of the data-warehouse.
• Good understand of the SSIS, SSMS, and SSRS.
• Created and modified reports to fulfill the contractual or regulatory obligations to the state.
• Gathered requirement on the input and output files for the ACG Engine 11.0.1 and 11.1.
• Created user stories to enhance and modify the output files (Stratification of Members) from ACG engine to be consistent with current table structures.
• Created the AS-IS Visio diagram of ACG process and the list of input files required for each Line of Business (LOB.)
• Used Pega systems' Care Management Framework to customize and deliver care plans for individuals, managing utilization management, disease management and case management specialties.
• Created As-Is model of in-house project for Care-Model, which utilizes the ACG and various outputs to stratify the CS member and set them into the queues for Care-managers in the front end to setup a touch point for complex categorized members to fulfill the contractual obligations.
• Created NCQA regulatory, LexisNexis SocioEconomic Data Pull and Sherlock Benchmarking report from scratch.
• Created user stories to migrate multiple tables hitting Teradata for Member Profile data to EDW. Overall good understanding of Member Profile form both front-end and back-end perspective.
• Responsible for translating BRD into functional specifications. Closely coordinate with business users and technical delivery team to negotiate the deliverable of project within the deadline provided.
• Documented the migration of processes from Informatica to SSIS.
• Documented the decommissioning of Teradata and after effects to the in-house applications currently connected to Teradata like Member Profile, Behavioral Report, and Stratification tools.
• Team player and assisted development team to gain better understanding of the complex projects and solution them in the most efficient way.

Environment: Visio, MS Office, Enterprise Datawarehouse, Teradata, Pega, ACG Engine, Milliman MUGS, Windows XP

Confidential, Durham, NC

Business Analyst

Responsibilities:

• Communicated business priorities to the organization to effect business solutions.
• Created and maintained BRD to assist Business PM close basis while managing multiple Claims projects.
• Converted Business Requirements to the Functional Specification.
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams thus defining the Data Process Model and Business Process Mode.
• Conducted JAD sessions to gather and document requirements that enhance a wide range of functionalities including Claims processing, eligibility and enrollment, provider networks, and electronic data interchange for our Facets core application.
• Elicited requirements from Business users, Business owners, enrollment and billing Technician, and analyzed new requirements, and business rules for Facets System User Interface (UI). CareFirst BlueCross BlueShield housed their various products and data in Facets data tables in the Facets backend database.
• Gathered requirements and developed Process Flow diagrams in accordance with CareFirst and Medicaid business rules and regulations pertaining to the Facets configuration and evaluated the impacts of proposed changes.
• Experience in configuration of Claims adjudication systems, i.e., FACETS & MMIS. Experience with ITS systems involved in Blue Square applications.
• Involved in Sprint planning sessions to identify the features and functionalities that should be achieved by the new application. Identified various points of integration among the new and existing applications and required integration with other IT components.
• Created documents and draft UML Diagrams using MS Visio for Membership Enrollment according to the HIPAA 834 Compliance Standards for Membership Enrollment.
• Analyzed the Application to scope out errors after submittal of transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment), 276-277 (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Converted business requirements into functional requirements.
• Worked on EDI Health Care Claim Payment/Advice Transaction Set (835)
• Set Claims processing data for different FACETS Module.
• Validated EDI Claim Process according to HIPAA compliance

Environment: Rational Unified Process, Rational Rose, UML, Pega, Visio, MS Office, Blue Plans, ITS, FACETS, MS Project 2002, Ms FrontPage, Windows XP

Confidential, CO

Business Analyst

Responsibilities:

• Responsible for developing in-house application comparing data from different sources i.e. EDI, XML and FACETS.
• Performed requirements gathering and analysis; interview the subject matter experts, stakeholders and executive sponsors.
• Interacted with the business analysts & business users for design & requirement clarification for external projects & change requests.
• Gathered requirements for different products and do the gap analysis for the products.
• Gathered requirements and prepare business requirement documents (BRD). Responsible for translating BRD into functional specifications and test plans. Closely coordinate with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Constantly interact with the Product Director for enhancements and discussion on the changes.
• Work on EDI X12 transactions, HIPAA standard transaction codes including 837, 834, 835, 270, 271, 276, 277 and perform analysis of such transactions.
• Extensively worked on PEGA tool to update the status of the project in order to be able to meet the internal audit.
• Wrote use cases for the Escalation & Reconciliation Management System (ERMS) Pega Application to include adding Billing Errors Application to the Applied Suspens and Dual Enrollment Applications SDS. Have knowledge of Capitation, Medicare, Vendors, Billing & Enrollment, ID Cards, Claims processing and Automated Renewals process.
• Documented all the changes for the enhancements and recommended changes.
• Analyzed the current state and recommended changes for the future state of the products.
• Prepared and Reporting test cases for requirements.
• Participated in analyzing business requirements, Data Model Design, Data flow from various Sources to Target.
• Developed Business Process diagram to understand the whole workflow.
• Used TOAD to execute all SQL queries.
• Facilitated the requirement changes and fixes along with the release management team.

Environment: FACETS, ALM, Oracle SQL, SQL Server 2008, MS Access, Pega, MS Outlook, MS Visio, JAVA, MS Word, MS Excel, WebEx .

Confidential, Baton Rouge, Lousiana

Business Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
• Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry (270)
• Authored Data flow diagram, sequence diagrams and business process models that describe how the EDI Health Care Claim Transaction set (837) is used to submit health care billing information and encounter.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Involved in defining and documenting the vision and scope of the warehousing project.
• Utilized the knowledge of Facets system to perform the data warehousing of Facets system data into Teradata.
• Conducting business validations covering the following deliverables: Facets Providers, Facets Claims and Facets Membership areas.
• Involved in identifying and studying the FACETS system data and field-by-field analysis of Facets system for the attribute mapping purpose.
• Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage.
• Conducted interviews with management team and other stakeholders.
• Conducted and participated in the JAD session with the SMEs and project team members.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• Participated in weekly status meetings to present status and incorporate any digressions from the original scope.
• Carried out a thorough target data model assessment and risk analysis.
• Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast changing environment to achieve company goals.
• Participated in the walkthroughs and meetings specifically for Claims and Membership modules.
• Coordinate with Development and Business team to develop high level Business and Technical documents.
• Involved in the development of Business and Technical Requirements Document (BTRD) and Business System Design (BSD) document for the project.
• Designed Use Cases using UML and managed the entire functional requirements life cycle using SDLC.
• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Assistedand worked with the clients on the verification process for the requirement phase documents and assisted in Regression Test, System Test, and UAT.
• Implemented Standardized process throughout the Software Development Life Cycle (SDLC)

Environment: Windows XP, Unix, Facets, Rational Requisite Pro, MS Office, MS Visio, UML, Informatica, Mainframe, Teradata, IMS, SDLC