SUMMARY

• Over 6+years of experience in the Field of Business Analyst in Healthcare Industry. Specially in Medicaid & Medicare Claims, Child Welfare Programs, Case Management, and Eligibility
• Highly experienced in gathering requirements, interviewing senior level company officials to gather requirements for documenting project functional specification.
• Experienced in SDLC business analysis practices for replacing entire legacy Medicaid Management Information Systems (MMIS) with COTS Web - centric solution, aligned with principles of Service-Oriented Architecture (SOA) and Medicaid Information Technology Architecture (MITA) framework.
• Experience working in Provider configuration in Facets front end and reconciliation of provider data in the back end.
• Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis & compliance experience from, payers, providers and exchanges perspective, with primary focus on Coordination of benefits.
• Experience in working with Medicare and Medicaid projects
• An excellent knowledge of ICD-9 and ICD-10 structures and formats
• Well experienced with the complex tasks of ICD 9 to ICD 10 conversion and mapping
• Excellent knowledge of HEDIS, HIPAA ANSI X12 4010, 5010 formats including EDI transactions such as 270, 271, 276, 277, 835, 837, 999.
• Exposure to all the 75 measures under HEDIS and enhancing the measures in the EHR to record useful data for healthcare quality improvement.
• Worked on Facets systems were used to enable inbound/outbound HIPAA EDI transaction including Claims, enrollment and billing.
• Involved in writing complex SQL queries to extract the data from Oracle database.
• Expertise in Claims, Subscriber/Member, Plan/Product, Provider, Commissions and Billing Modules of facets.
• Experience in working on FACETS environment and possess an extensive knowledge about various modules of FACETS system such as claims and membership
• Well versed in EDI 834 Membership Enrollment process
• Extensive experience working on Facets Claims Processing, Billing and Medical Provider application groups
• Worked as system analyst, in Facets upgrading, system support, and migration support.
• Performed Profile Changes, Security tracking and worked in deploying codes in different environments
• Experience in working in Oracle RDBMS.
• Some hands on experience working on automation tools such as QTP.
• Experience in working on Web Applications.
• Worked on healthcare standards such as HIPPA 5010, 4010, ICD-9 & ICD-10.
• Extensive experience in Functional, Integration, Regression, & User Acceptance Testing (UAT).
• Good Management, Execution and Documentation skills.
• Expertise in all areas of software development including client interaction, requirements gathering, analysis and tele-conferencing with the client during the progress of the project.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Adhered to SDLC guidelines to maintain optimal quality in work processes.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277)

TECHNICAL SKILLS

Project Management: MS-Project, MS-SharePoint, MS-Office

Project Methodologies: Waterfall, Agile-Scrum, Rational Unified Process (RUP), UML

Business Modeling Tools: Rational Rose, MS Visio/Project

Requirement Management Tools: Rational RequisitePro, Rally

Defect Tracking Tools: Rational Clear Quest, Quality Center, ALM, Test Director

Operating Systems: Windows R2008/NT/XP/2000, UNIX

Database: Access, Oracle, SQL server, DB2, Teradata

Quality Assurance: Software Application Testing Life Cycle

Business Applications: Microsoft Office Suite, MS VISIO, MS Project, SharePointBI-Data migration/Reporting: ETL (Informatica), Hyperion, Oracle, SQL, Auto-sys.

PROFESSIONAL EXPERIENCE

Confidential, NC

Business Systems Analyst

Responsibilities:

• Reviewed, analyzed and evaluated business systems and user needs and formulated systems to parallel overall business strategies.
• Gathered and defined business requirements for and created client disease management / HEDIS data dashboard reports in direct consultation with client.
• Document the requirements, define scope and objectives of the user needs, organize requirements and develop the document to define the user needs, functionalities and features of application that needs to be developed and implement in order the accommodate the changes in the existing Facets modules; Membership-Subscriber/Member, Claims Processing + ITS.
• Worked on CAMS (Claims, Analytics and Membership) incidents, intake form in order to triage the problems within the Facets systems in claims and membership management.
• Worked on Quick base web based incident management portal to resolve the problems/incidents assigned in order to resolve the problem.
• Analyzed configuration across Medicaid lines of business.
• Associated with full HIPAA Compliance life cycle from gap analysis, mapping, implementation and testing for processing of Medicare, Medicaid and Tri-care claims.
• Facilitating JAD sessions with the Configuration Team and the Project Manager for brainstorming to arrive at best practices for the process of Facets configuration.
• Involved in Medicaid business configuration with focused primarily on claims adjudication, pricing, provider, member, enrollment, ISP/IEP Plans.
• Explored the Facets issues, identified the core facets issues in relation to data/record duplication, omission, and record not being able to get updated. Such as paid thru date for the member/group.
• Assisted in user acceptance testing, gathered the data types and validated the functionalities and features for the prod implementation from p-stage environment.
• Conducted User Acceptance Testing (UAT) sessions with business users and prepared document for enhancements and bug fixes.
• Coordinated with release management to implement the releases and upgrades into the Facets system in prod environment.
• Created incidents on TFS (Team Foundation Server) for issues/problems to be triaged and resolved.
• Performed the data analysis and data e-governance within the migration and integration of the application. Such as generating the ACS vendor feed file from the facets application, HEQ feed file for successful creation of subscriber/group health equity data.
• Worked in between the integration of different databases to Facets. Such as Blue connect, Siebel, BOL, ACS, HEQ and various other web services.
• Worked on implementation of different modules of Facets 5.30.004
• Performed sole responsibility of issue resolution with different team members and functional areas.
• Worked on (HIPAA) Facets EDI 837-I/837-P claims (Facility and Professional), on line item details, line item pricing, Total and line totals.
• Worked with the business/configuration unit to assist in the development, documentation, and analysis of Functional
• Work on Facets membership, EDI 834, Indicative-member info, Group/Subscriber/member eligibility, Plan/Product codes, eligibility inquiry, class group, subgroups, Premium Rates/Overrides, HSA/HRA.
• Coordinated at the time of Data migration in between the system databases and accessed the risk factors for the volume of claims.
• Worked on member/group management, Premium pricing, member enrollment history overlaid, On-Exchange vs. Off-Exchange issues in facets.
• Wrote test cases using the Business Requirement Document and the Design Configuration Document.
• Worked on risk tier being changed when maternity add/update information.
• Worked on EOP (Explanation of Payment) RA (Remittance Advance)and EOB(Explanation of Benefits)
• Worked on claims to hold, duplicate, pend, and adjust the deductibles, co-payments, allowed amount and non-covered amounts, depending upon the different cases to adjust the appropriate logic.
• Validated the EDI 837 claims for the diagnosis and procedure codes in Facets.
• Validated the member information in the Subscriber/member modules of Facets for various tests, such as eligibility, claims procedure, plan/product id and other information.
• Executed various claims Inquiry using SQL queries and other tools to validate data for member/group data validation, plan verification, enrollment period assessment and claims data validation.
• Validated the claims data for plan retro switch cases on both on exchange and off exchange cases for dental, medical and (Rx) Pharmacy cases.
• Worked on Medicaid reclamation claims, Desktop process, Medicare and other institutional and professional 837 claims.

Environment: s: Facets, JAVA, SQL, Oracle, Management Studio, My SQL, UAT, UNIX, Soap UI, Web services, web now, Edifecs, BOL, and Siebel. RDBMS, HEQ, Connecture, Power MHS, Client-server, Quickbase, MS office, SharePoint/document library.

Confidential, FL

Business Systems Analyst

Responsibilities:

• Developed Use Case / Analysis / Design / Implementation Model, Use Case Diagrams, Behavior Diagrams and Class Diagrams based on UML methodology using Rational Rose. Created app to XML, app to SQL and vice versa maps using AI mapper for new customers in X12 5010 standards and moved them into production.
• Analyzed the Facets Requirements by Conducting Gap Analysis using the ‘AS-IS, TO-BE’ model.
• Involved in loading the flat files into Oracle Database and involved in writing SQL Queries.
• Worked with data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Analyzed the Business and System requirements using HP ALM and developed detailed Test Plans Conducted business validations covering the following deliverables: Facets Providers, Facets claims and Facets Membership.
• Developed Schemas of EDI ANSI X12 Claims (837) and Eligibility forms in XML.
• Converted the enterprise ICD-9 Business rule to ICD-10 formatted rules using the EDIFECS conversion.
• Attended Daily Scrum Meetings and Design Review meetings.
• Attended meetings on cross walking between ICD9 and ICD10
• Involved in Hospital and Medical and adjudication claims.
• Worked on McKesson Claims for billing and claims EDI transactions.
• Worked as system analyst on System Support, data migration and data, meta-data validation.
• Tested EDI transaction on McKesson Claims X-ten module.
• Tested and validated processing of the claims on the NASCO and McKesson’s Claims X-ten product.
• Used Edifices Spec builder to improve transaction quality and achieve compliance by testing tractions.
• Created and maintained SQL scripts and Unix as a part for back-end testing on the oracle database.
• Conducting business validations, covering the following deliverables FACETS Providers, Facets Claims and Facets Membership and Operational reports .
• Worked with Medicare, Medicaid and HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Transactions tested were 820,834, 835, 837, 270, 271, 278 on Edifecs Spec Builder
• Worked Extensively with Inbound 837 I and 837 P, 835s(Out bounds) claims processing systems
• Performed system analysis, provided valuable insight in system upgrade, system support, migration support as part of regular SDLC.
• Performed profile changes, security tracking, code deployment analysis, researched the issues,
• Executed the SQL queries in Oracle
• Tested the application using Browser Compatibility testing, System Integration Testing and Smoke testing
• Tested the application using End to End testing, Functionality testing, Regression testing
• Created customized dashboard graphs and analysis reports in ALM.
• Have tested web services.
• Involved in 820,834, 835, 837, 270, 271, 278 testing and led the team in writing hundreds of test cases related to EDI transactions.
• Created complex SQL queries using SQL editor.

Environment: MS Office, ALM, SQL Server, SDLC, Windows, McKesson’s Claims, UAT, SharePoint, Oracle, Quality Center (ALM)

Confidential, Southfield, MI

Business System Analyst

Responsibilities:

• Involved in business analysis and project management, coordinating between the team members, addressing budget issues and creating test plans according to the business requirements.
• Created and maintained quality measures such as P4P, HEDIS, STAR etc. using clinical alert tools.
• Conducted business validations covering the following deliverables: Facets Providers, Facets claims and Facets Membership.
• Involved in preparing “BRD” Business requirement Documents for 5010.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center mangers and stakeholders of the project.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• As a system analyst, I was involved in complete SDLC process in upgrading Facets system, system analysis, system support, migration support, profile changes, security tracking, and code deployment.
• As part of UAT test execution and report team, I was involved in researching the issues from various system perspectives for example tracking the log files in the system and finding the root cause of the issues.
• Executed the SQL queries in Oracle RDBMS to retrieve data to perform tests into the facets modules. Such as member data validation, diagnosis data validation
• Conducting business validations, covering the following deliverables FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Worked as system analyst on System Support, data migration and data, meta-data validation.
• Worked on data profiling, tracking security issues, defect tracking, deploying codes, researching and trouble-shooting the issues.
• Sourced procedure codes and medications from the data store of FACETS claims.
• Actively prioritized and managed requirements throughout SDLC with all key stakeholders.
• Analyzed a wide range of Trizetto FACETS configuration change requests for the purposes of determining the technical scope of the change, its impact on existing systems configuration
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Analysis and Design of the Facets data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Gathered requirements, developed Process Model and detailed Business Policies.
• Designed Use Cases using UML and managed the entire functional requirements life cycle using RUP.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Involved with the coders in evaluation of CPT and ICD-9 codes to ensure that the diagnosis meets medical necessity for the specific CPT code.
• Performed impact analysis for readiness of ICD-10 conversion
• Followed the RUP methodology for the entire SDLC.
• Involved in writing and implementation of the test plan, and various test cases for UAT.
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Worked on developing the business requirements and use cases for Facets batch processes; automating the billing entity and commission process
• Initiated, proposed and implemented critical analytical and technical turnkey solutions extensively increasing the quantitative and qualitative value of the application.
• Involved in project planning, coordination and implemented QA methodology.
• Provided overall project management to multiple projects successfully completing them on-schedule and on-budget.
• Worked on Facets upgrade, system support and Data migration from legacy system to Facets modules
• Used SDLC and Agile Methodology for the project
• Written requirements following SDLC methodology, converted them to User Stories in order to follow agile development.
• Worked with FACETS, eBilling and EDI HIPAA Claims (837/835/834) processing.
• Prepared the Business Workflow using MS-Visio with input, output, and Pre and Post conditions.
• Enhanced test cases and scripts by adding the required functionality as per the new business requirements.
• Defect Tracking and Bug Reporting was performed using Quality Center.
• Performed manual testing on different modules of the application.

Environment: MS Visio, Rational Requisite Pro, SDLC, MS Project, RUP, UML, UAT, MS Office, Facets, Windows 2000, SQL.

Confidential, Atlanta

Business Analyst

Responsibilities:

• Facilitated JAD sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system.
• Profound understanding of insurance policies like HMO and PPO and proven experience with HIPPA EDI transaction codes such as 834/837.
• Improved STAR HEDIS ratings by decreasing member and provider abrasion.
• Worked as system analyst on System Support, data migration and data, meta-data validation.
• Involved in requirement gathering phase (Provider, Claim components and HIPAA)
• Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• As a system analyst, performedcomplete SDLC process in upgrading Facets system, system analysis, system support, migration support, profile changes, security tracking, and code deployment.
• As part of UAT test team, I was involved in researching the issues from various system perspectives for example tracking the log files in the system and finding the root cause of the issues.
• Performed root cause analysis in researching issues, security tracking and profile changes.
• Executed the SQL queries in Oracle RDBMS to retrieve data to perform tests into the facets modules. Such as member data validation, diagnosis data validation
• Conducting business validations, covering the following deliverables FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Upgraded, tested and implemented maps, applications and trading partners from X12 4010 standards to 5010. Used EDIFECS Analyzer to compare the standards.
• Met with report users and stakeholders to understand the problem domain, gathered 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.
• Prepared “FSD” functional specification document for 5010 from 4010A and changes in ICD 9 to ICD 10.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional requirement.
• Implemented automated COB processing of Medicare claims into Facets
• Validated business rules and all artifacts with users, got approval and sign off.
• Performed the detail comparison between 4010A and 5010 to identify differences across loop Structures.
• Followed Unified Modeling Language (UML) methodology using Requisite Pro and Rational Rose to create/maintain: Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams.
• Performed gap analysis for migration of HIPAA transactions from 4010 standard version to 5010 standard version.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• Assisted Design Team in preparing SRS, Software Design Document (SDD), User Interface Design, and Application Architecture & Database Modeling.
• Helped in project testing efforts for doing integration tests, regression tests and user acceptance tests.
• Used Performed Gap Analysis between 4010 and 5010 version of transaction sets 837I/P/D, 270/271,276/277
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Made sure that the systems complied with the rules of HIPAA.
• Documented the dimensional models of ETL system.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment

Environment: Java, MS Office Tools, Windows XP, MS Project, RequisitePro, Rational Rose, Clear Case, PowerPoint, SharePoint, MS-Word, MS-Excel, Informatics, IBM Process Modeler, UAT, Facets 4.21.

Confidential, Newark, DE

Business Analyst

Responsibilities:

• Responsible for the requirement-gathering phase and project plan.
• Responsible for requirements analysis, design and developing technical requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Performed system analysis, root cause analysis, data migration support, system support and security tracking.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
• Worked on Facets upgrade, system support and Data migration from legacy system to Facets modules.
• Used Requisite-Pro for writing/analyzing project vision, goals, specifications and requirements.
• Conduced Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.)
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Performed system analysis, root cause analysis, data migration support, system support and security tracking.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Performed configuration/ compatibility and user interface testing manually.
• Worked with QA lead in validating Test Plan and Test Scenarios.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release
• Review of high-level design document and low level design of classes and sequence diagrams.
• Ensuring that deliverables were delivered on time as scheduled.

Environment: s: UML, RUP, Rational Requisite Pro, Rational Rose, Facets, UAT, Rational Clear Quest, Excel, SQL, DB2, Crystal Report, HP Quality Center