SUMMARY

• 13+ years of consulting and industry experience in Business Analysis, System Analysis, data Analysis, Systems design, Mainframe development and QA.
• Product Owner for Population Health Management Products.
• Data Analytics lead for various markets and CMS and NGHS Audits.
• Expertize in Requirements Gathering and Analysis, Requirement Specification, Business Process Analysis and Use Case Documentation - for Agile projects
• Excellent writing skills in creating Business Requirement documents (BRDs), System Requirement specifications (SRS), System Design Specifications (SDS), Functional Specifications and defining project plans.
• Well versed in Requirements/Change Management, Impact Analysis and Gap Analysis
• Accomplished experience through whole SDLC from requirement analysis till deployment.
• Participate in winning proposals (RFPs) for organization by providing Healthcare solutions and acting as Healthcare SME.
• MicroStrategy Solution Architect for client specific Reports.

TECHNICAL SKILLS

• Healthcare domain expertise
• Membership, Provider, Benefits/Benefits Migration
• Claims adjudication, Payment, EOB/EOP.
• NASCO, QBlue, QNxt, ITS, CPL, Identifi, FACETS.
• EDI Transactions - 834, 837 I/P, 270/271, 276/277 and 835.
• HIPAA, PHI, HL7
• Healthcare Reforms - 5010 and ICD10 initiatives.
• Medical Management System (MMS) - Care Radius, Identifi.
• Population Health Management, Care/Utilization Management.
• Appeals, SLA, Compliance and Grievance process
• Business and Data Analytics, MicroStrategy BI
• CMS and NHGS Audit
• COBOL, SAS, REXX, SQL.
• IMS, DB2, VSAM, MS-SQL
• QMF, SPUFI, Fileaid, Xpeditor, Endevor.
• Mercury Test Director, RequisitePro, Clearquest, Clearcase, Visual Source Safe, TFS, VSTS
• SharePoint Designer
• SQL Server Management studio
• MicroStrategy BI Reports
• Azure Environment migration

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business Analyst

Responsibilities:

• Product Owner for Identifi Care (CM) and Identifi Reporting applications.
• Coordinate the Azure environment migration effort
• Data Analytics consultant for client specific slicer reports.
• Single point of contact for CMS and NGHS Audit requirements.
• Requirement gathering and documentation of same for Identifi Utilization Management (UM).
• Work on Agile platform and create User Stories and Use Cases for Evolent’s population health management solution applications.
• Provide demo of the applications in the sprint demo meetings.
• SME for main functional areas such as Care Plan, Care gaps, Problem, Goals, Interventions (PGI), Authorizations, Appeals and SLA configuration.
• Integration of Pharmacy module into Identifi Care suite - Medication Review and Med reconciliation
• Single point of contact for the NOVI Assessment tool Integration with Identifi Care Applications.
• Single point of contact for new Complaints module within Identifi application - Created POC for the same.
• Gather requirements for Evolent’s Business Intelligence tool MicroStrategy for various reports.
• SharePoint designer for the IT Product Management team.

Confidential

Lead Consultant

Responsibilities:

• Conduct JAD sessions with Stakeholders and users to understand the requirements of various Work requests and enhancements in Horizon s benefit application repository called CPL, customized by FJA.
• Perform downstream system impact analysis and create approach documents.
• Participate in Business Modeling by understanding the needs of the business, and also document Business Use Cases as well as System Use Cases.
• Analyze and capture requirements for successful implementation of new Integrated Medical Management system, Care Radius that offers full suite of medical management functions.
• Ensure new Medical Management system (Care Radius) has all the functionalities implemented that will replace the old system, Care Planner Web (CPW) without any gaps.
• Played key role in Horizon s major initiative to meet ICD 10 complaint.
• Acted as one point contact for ICD 10 project that includes complete systems and process analysis, application design and programming, internal testing, training, and external testing with trading partners.
• Proposed strategies for Horizon to optimize process, improve system transactions and utilize a richer data set for many internal functions that will allow for more efficient operations and potential reductions to errors and omissions.
• Implemented solution with incorporation of the ICD - 10 enhancements while maintaining the ICD-9 functionality.
• Performed Impact analysis and Gap analysis for ICD 10 and ensured a smooth migration.
• Received many client appreciation and star performer award for the successful implementation of ICD 10 project.
• Single point of contact for the QBlue HOS Migration project
• Conduct JAD sessions and gather requirements from different stakeholders and individual Claim engines SMEs for migrating claims into NASCO from QBlue.
• Prepare BRDs and Process flows for Accumulator, Authorizations, Referrals and COBs for different claim engines.
• Propose new screens and new fields in existing CICS screens in NASCO to accommodate claims from different engines.
• Validate Use cases and assist in UAT testing
• Proposed strategies to migrate benefits from Lotus Notes forms such as BIFs, NAEGs and GEI to web based product, CPL, customized by FJA.
• Created and presented many POCs (Proof of Concept) for CPL migration project.
• Build a team of Business Analysts and Technical Analysts at onsite and offshore and lead the project.
• Worked with IBM team to create Views in Lotus notes forms and guided team to create Agents to export data from Lotus Notes forms.
• Proposed strategy to create Interim database to load benefit data and capture errors before loading into the actual CPL database, which resulted in huge savings for Horizon.
• Received many appreciation for the successful implementation of the CPL product and in honor the interim database was named as Nisha s database in Horizon.
• Analyze NASCO claims scenarios and EOB/EOP messages to check the appropriateness of the EOB/EOP messages generated.
• Conduct SME review for EOB/EOP message codes and recommend verbiage to give more clarity on the message passed.
• Review and eliminate the duplicate EOB/EOP messages and make the messages unique.
• Fix the glitches in the EOB/EOP generation system with respective to claim scenarios and make sure the messages are CMS and DOBI compliant.

Confidential

Associate

Responsibilities:

• Sr Business Analyst for NASCO BlueCard ITS application.
• Propose strategies and solutions to support claims, inquiries, membership, provider data, financial information and performance standards enhancement.
• Coordinate global Certification testing and Partner plan testing with other BCBS.
• Sr Business Analyst for Legacy System to Facets Migration Project.
• Acted as the system owner for FACETS - ITS Claims adjudication module and ensured smooth migration of the claims adjudication module to Facets.
• Worked on EDI Transaction 837(I, P, D) - Healthcare Claims input.
• Coordinated partner plan testing for BlueCard.

Confidential, Basking Ridge, NJ

Responsibilities:

• Business System Analyst for the NDB - Provider Data application.
• Business Analyst for the 5010 and ICD 10 Initiative for NDB application.
• Impact Analysis of different EDI Transactions such as 270/271 - Eligibility, Coverage or Benefit Inquiry/response, 835- Health Care Claim Payment/advice, 837(I,P) - Healthcare Claim, 834 - Benefit Enrollment Request and status.
• Gap analysis for HIPAA 5010 and ICD 10 initiatives.
• Support various enhancement projects for PRIME Admin where the Administrative part of the policies like New Business, Plan changes, ID cards processing, eligibility, downstream feeds, external / internal interfaces is handled.
• Support various enhancement projects for EXBA which is maintained for the billing and adjustments.
• Developed many Mainframe programs to support the enhancements for PRIME and EXBA.
• Propose strategies to sunset EXBA application and ensure successful implementation of new Web application eBill.
• Received Star performer award for implementing new MQ system to connect Prime eBill with downstream PeopleSoft application.
• Acted as Release Engineering coordinator and coordinated all release activities for the Major release for PRIME in June 2007.