SUMMARY

• Experienced IT business analyst with an overall experience of 8 years in health plan and pharmacy benefit management value chain. Good team player with excellent analytical, interpersonal and problem - solving skills.
• Experience in business requirement analysis and documentation, business process analysis, requirement traceability matrix, test plan and test case creation, defect analysis and resolution.
• Functional areas of expertise include: Benefit configuration, Claim Entry and Adjudication, Group, Member configuration within health plan and Benefits and Clinical (formulary and utilization management) in PBM with unique experience in Govt. (Medicare and Medicaid) as well as Commercial lines of business.

PROFESSIONAL EXPERIENCE

Confidential

Business Analyst

Responsibilities:

• Worked with client SMEs to elicit and document benefit & clinical business requirements for Medicaid, Medicare, and Commercial line of business.
• Conducted requirements gathering sessions and provided walkthrough of the BRD for approval and sign off.
• Translated and simplified business requirements to the coding team to ensure the requirements are coded correctly in the system.
• Developed detailed test cases/use cases for user acceptance testing based on business requirement and walked through the test cases with business team to review, approve and sign - off on the test cases.
• Performed UAT testing in Rxclaim test environment to ensure the Formulary & Utilization Management (UM) drug list edits(Prior Auth,Quantity limit, Step therapy etc) loaded behave as expected during the claims adjudication process to either pay/reject based on the intended requirement and provided walkthrough of UAT test results for business sign-off
• Identified, analyzed and communicated defects discovered during testing to the stakeholders and meticulously documented defects in JIRA defect tracking system.
• Facilitated daily review meetings with internal and external business work streams to review benefits and clinical related issues/clarifications.
• Performed business process analysis to understand current process and proposed solution to automate the manual effort in performing clinical validation for maintenance of business tasks.
• Created Standard operating procedures(SOP) to cover detailed aspects of validation process and fields to validate for each functionality for Medicare/Medicaid/Commercial benefits and clinical thereby reducing the time spent on validating each benefit and clinical scenario by 50% and meeting productivity goals. This also helped in identifying issues quickly.
• Understand business process to automate daily clinical validation tasks
• Participated in war-room with clinical business team to support go-live implementations. Analyzed production issues and performed testing in test environment to validate if code fix is meeting the change requests submitted.
• Prepared and reported testing summary report with status, milestones and issues to stakeholders related to on a weekly basis.

Confidential

Business Analyst

Responsibilities:

• Worked with clients to gather, document business requirements for small scale change requests or enhancements.
• Logged and tracked production issues/enhancement requests in OPAS incident management tool.
• Analyzed production issues to identify if issue is related to user entry error or claims system error
• Logged, prioritized and assigned the defects identified in production in Clear Quest defect tracking tool.
• Performed testing and documented the steps taken to recreate the defects.
• Worked closely with development team to resolve the issues in a timely manner to reduce member impact.
• Facilitated meetings with business and development teams to resolve issues
• Executed SQL queries to analyze and perform data analysis from the database
• Reported status, milestones and issues to management and other stakeholders related to assigned work items.
• Conducted and provided user training manuals for enhancements
• Load and validated the 837(profession, institutional) X12 and XML files in HIP(health insurance portal).
• Performed detailed analysis and extensive testing on how claims interest and penalty functionality can be used in the current Xcelys system and identified gaps based on business needs. The implementation of this functionality eliminated/reduced the incorrect payment of claims

Confidential

Business Analyst/QA tester

Responsibilities:

• Analyzed benefit plans to determine the best approach for configuring existing and new benefits.
• Documented and created medical and pharmacy benefit rules to support the configuration for member cost shares like copay, coinsurance, deductible, out of pocket maximums and validated accumulators for the correct accumulation of amounts in the Diamond 950 system.
• Designed a new approach on the creation of a QA process to be used in the test execution phase. The design process helped the QA team in automating the testing effort and perform execution more efficiently.
• Created a library of unique test cases for professional, institutional and pharmacy claim types to be used during test execution.
• Performed unit testing to validate the claim outcomes for correct application of benefits and ensured the work product met the client’s expectation.
• Debug and troubleshoot claims event encountered and validate outcomes against configured benefits.
• Communicated accurate and detailed status reports to clients on a weekly basis.
• Mentored and assisted new team members in the event of benefits configuration and defect resolutions.

Confidential

QA tester

Responsibilities:

• Analyzed Business and Functional requirements document for the Claims System projects.
• Created test case document based on the requirements to ensure extensive test coverage.
• Created Requirement Traceability Matrix to ensure that all requirements are covered by test cases.
• Identified and created test data to execute test cases.
• Executed test cases and accurately monitored and recorded results in test documentation.
• Identified and reported defects and communicated to developers to swiftly resolve defects.
• Conducted regression testing to validate existing functionality.