SUMMARY

• 6+ years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Highly motivated team player with excellent communication, presentation and interpersonal skills, always willing to work in challenging and cross - platform environment.
• Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health Insurance
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Created and maintained requirement documents for Facets for the different modules like Billing, Member enrolment and Claim adjudication.
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications
• Expertise in Healthcare, Health Information Exchange (HIE), Electronic Health Records (EHR), Electronic Medical Record (EMR), Electronic Data Interchange (EDI) and HIPAA regulated environment projects.
• Extensive healthcare experience in Medical Imaging, EHR/EMR, Mobile Apps, Medicare-Medicaid, HIPPA, HIX on EPIC software applications
• Experience in Healthcare Payer and Provider Operations, re-engineering claims, benefits, enrollment and eligibility processes Experience with different modules within healthcare (Sales, Membership, billing, enrollment, claims, capitation, and providers).
• Good understanding of MITA and MMIS functional business areas which include claims, provider’s services, provider’s enrollment, recipient services etc.
• Extensive working experience with HL7, EDI X12 transactions, Facets, claims process, HIPAA, Billing Process etc.
• Worked on Health Care Eligibility Benefit Inquiry and Response (270/271) version 5010A1, release 005010X279 E1, A1 transactions, Health Care Remittance Advice (835) X12N 5010 X221A1 transactions, Health Care Claim Institutional Transaction (837I) X12 5010 X223A2 transaction standards, Health Care Claims professional (837P) X12N 5010 X222 A1 transactions standards, NCPDPD D.0 and 1.2 transactions (B1, B2 and E1).
• Used Computer Media Claims (CMC)/EDI X12 claims - 837I and 837P, Pharmacy claims - NCPDP D.0 and 1.2, Paper claim forms - UB-04, CMS-1500, Pharmacy 30-1, Compound Drug Pharmacy 30-4, RTIP (Real Time Internet Pharmacy) and IPCS (Internet Professional Claims Submission) for claim submission.

TECHNICAL SKILLS

Modeling Methodologies: Agile, Rational Unified Process (RUP) and Waterfall

Process/ Modeling Tools: Rational Rose, MS Visio, Lombardi

Databases: MS Access, SQL Server, SSIS SSAS SSRS

Quality Management: HIPAA, CMMI, CMM

Languages: SQL HTML, C, C++

Project Management: MS Project

Healthcare Tools: Trizetto Facets, Claredi, Amisys, QNXT, JIRA

PROFESSIONAL EXPERIENCE

Confidential, Hartford, CT

Sr. Business System Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Analyzed and developed business and functional requirements-BRD, FRD for the Financial Client Reporting website including Medicare part D Banking Payment Option for the members & Clients in the Company Home Page. Worked Extensively with Inbound 837 I and 837 P, 835s (Out bounds) claims processing systems.
• Extensive healthcare experience in Medical Imaging, EHR/EMR, HIX on EPIC software applications.
• Conducted data research to resolve healthcare Medicare/Medicaid eligibility, enrollment and billing issues. Developed Schemas of EDI ANSI X12 Claims (837) and Eligibility forms in XML.
• Closely worked with business users and clients for processing of different transactions at EDI Gateway such as Benefit Enrollment and maintain (834), Healthcare Payment (835) and claims (837). Worked on regulation and services including HIPAA, Medicaid and Medicare.
• Involved in development of the system for data exchange from EMR, EHR to Electronic Lab Reporting Systems.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set.
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Worked on Customer Support module on facets and reviewed various customer transactions using the FACETS application.
• Responsible for conducting the overall System Testing to verify operations of key FACETS modules involved in the processing of claims (including benefits), providers and members.
• Gathered requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
• Expertise in performing Bug and Defect management using bug-tracking tools like JIRA and HP QC/ALM.
• Involved in the development of Business and Technical Requirements Document (BTRD) for the project. Participated in the JAD session with the SME’s and project team members.
• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Wrote Test Cases in Excel based on Technical Specifications, Functional Specifications and Business rules for online application system
• Wrote SQL queries for data validation, analysis and manipulation, and maintaining the integrity of the database.
• Involved in data design and created and maintained databases objects, complex Stored Procedures, Triggers, and Tables, Views and SQL Joins and SQL statements for inserting/modifying/deleting data in relational tables.
• Designed Data mapping and filtering, consolidation, cleansing, Integration, ETL, customization of data mart.
• Used data analysis techniques to validate business rules and identified low quality missing data in the existing enterprise data warehouse (EDW).
• Participated throughout the Extraction, Transformation, and Loading (ETL) process of data mapping, cleansing, standardization and implementations.
• Created various Informatica mappings and mapplets to load the data mart. The mappings involved extensive use of transformations like Aggregator, Filter, Router, Expression, Joiner, Sequence generator.
• Created dashboards, metrics, analytics, goals, alerts using Business Objects to streamline processes and procedure.
• Created reports using Business Objects functionalities like Drill down, @functions, Cross tab, Chart, Formulas, etc.

Confidential, Hillsboro, OR

Business Analyst

Responsibilities:

• Reviewed CMS regulations of EGWP and PDP programs and translates regulations into business requirements.
• Discussed and applied Rational Unified Process (RUP) and Agile (Scrum) methodologies, indicative to System Development Life Cycle (SDLC) with Project Manager and Senior Business Analyst.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set.
• Wrote different SDLC documentation: BRDs, FRDs, Process flow diagram, test scenarios on TrOOP, Co-pay calculations, COB, EOB, Plan finder, Retro Changes and PDE creation and PDE reject handling.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Used Data warehousing for Data Profiling to examine the data available in an existing database.
• Design, development, implementation and roll-out of Micro strategy Business Intelligence applications
• Prepared several use cases, designed use case diagram and process flow diagram.
• Created and executed test plans that improved data warehouse report quality using Word, Excel and Access.
• Performed Data analysis from the data warehouse along with business intelligence solutions delivery team.
• Reviewed existing functional practices and recommends modification to processes or new strategies in meet business requirements.
• Involved in testing and reporting of errors of subsequent builds during the process of development and production.
• Worked with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects.
• Created detailed mapping documents and technical specification documents mapping the fields between multiple databases and the reporting data warehouse.
• Align with the BOs for defining test scenarios; workflow (or business process flows) and training processes.
• Extensively involved in testing Trizetto's Facets and mainly involved in Enrollment and Eligibility modules.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Worked on preparing sprint backlog and user stories in agile scrum methodology with business users, developers, and stakeholders.

Environment: Rational Unified Process (RUP), Waterfall, HIPAA, EDI X12 (834, 835, 270, 271, 276, 277, 278, 837), IBM Rational Suite (DOORS, Rose, Clear Case, Requisite Pro), UNIX, UMLMS Visio

Confidential

Business Analyst

Responsibilities:

• Performed Requirement Analysis by gathering both functional and nonfunctional requirements based on interactions with the process owners & stake holders and document analysis, represented them in Requirements Traceability Matrix (RTM).
• Used clinical analyst and business analyst skills to document EMR system requirements, work flow and hardware assessments in the physician practice and clinic setting.
• Worked on Business Intelligence Analytical Reporting (BIAR), the base MMIS data warehouse subsystem, to extract and analyze Medicaid data and to support exchange of this data with various external data sources via a secure SFTP server.
• Observed and analysed corrections-specific workflows to adapt the EMR and optimize provider efficiency and success.
• Worked with SME’s in Finance, Investment, Commercial and Personal banking to collect the Business process requirements, documented them in Business Requirement Document (BRD) and performed Business Process Re-engineering.
• Enrolled members manually via 834 EDI transactions. Understood the loops and segments of 834 and involved in manually editing the Edi data via Text Pad
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Performed System testing of the Claims processing systems (Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment, et al).
• Trained the team on JIRA tool for Agile/ Scrum Methodologies and utilized JIRA to develop and track agile epics, stories and tasks.
• Knowledge on HIPAA Compliance EDI Transaction Sets 834, 837 and Good understanding of the EDI transaction sets 834, 837
• Communicate with vendor to regarding new updates on Facets and solution to their existing system
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports. Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc).Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA
• Used Facets support systems to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• Maintain knowledge on working of all HIPPA EDI protocols and map all data for various ERP systems and applications and perform audit on all EDI processes to maintain accuracy
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Interacted with department heads to finalize business requirements, functional requirements and technical requirements and also created Business process model.
• Used Rational Requisite Pro to improve the communication of project goals, enhance collaborative development, reduce project risk and increase the quality of application before deployment.
• Worked with the scrum master to get the estimates of the project for developing user stories and defining the sprint periods.
• Created and maintained Narrative Use Cases (Business Use Cases, System Use Cases) and modelled Use Case Diagrams, Activity Diagrams, Data Flow Diagrams using MS Visio.
• Fine-tuned search engines and pulled data from different databases and migrated data back and forth using SQL.

Environment: Windows XP, Oracle, PL/SQL, MS-Project, MS-Office Suite, MS Visio, Crystal Report Rational Requisite Pro, Clear Case, Clear Quest, Agile, MS Visual Source Safe, Test Director 7.6, Quick Test Pro (QTP)

Confidential, Round Lake, IL

Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application. Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Prepare and maintain project budget and forecast data, modify and enhance macros and code in MS Excel for corporate forecasting tool, assess business processes for spending effectiveness for the state health plan
• Effectively manage EHR staff by hiring, developing, training, and overseeing personnel to meet the needs of the practice
• Gathered requirements for making changes to the existing Electronic Medical Records (EMR), Electronic Health Records (EHR) and Ambulatory Services for the existing Epic Interfaces.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Worked with internal and external users to define requirements and coordinated user management and developer expectations.
• Executed project management functions including project planning(WBS), budgeting, business requirements, technical design, systems specifications, and project deliverables
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations
• 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.
• Designed High level design, for new process, integrating with legacy and Facets. Tested and delivered Inbound/Outbound Facets interfaces.
• Performed requirements modeling and develop analysis diagrams, activity diagrams, sequence diagrams, state diagrams, data models, and use-case realizations using RUP tools in Agile.
• Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
• Maintained proper communication with the developers ensuring that the modifications and requirements were address and also monitor these revisions.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence)
• Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.
• Performed (UAT) once QA Manager approved the application and it was migrated to the User Acceptance Testing Environment.

Environment: PL/SQL, AS/400, Windows 2000 Server, Mercury Quality center, Facets, Agile Methodology, MS Office, .Net, Rational Clear Quest, Rational Clear Case, Microsoft office, Word, Excel, Power point