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Edi Specialists Resume Profile


  • 6 years of experience in Health Care Industryworking as a Business Systems Analyst.
  • Several years of experience and advance knowledge of the Systems Development Life Cycle SDLC , and project life cycles such as Agile, Rapid Application Development RAD , Extreme Programming XP , andRational Unified Process RUP .
  • Proficient in creating business requirement documents BRD ,functional requirementsdocuments FRD , Use cases diagrams, Activity diagram, Class diagrams, and Sequence diagrams.
  • Actively participated and functioned in Joint Application Development JAD .
  • Well Experienced in Test Plans development, Test Conditions and Test Cases, test data creation and analysis, and interaction with the development team for error detection and correction.
  • Developed Requirements Traceability Matrix RTM using Rational Rose to trace each software requirement to test case.
  • Experienced in conducting GAP analysis, User Acceptance Testing UAT , SWOT analysis, Risk Analysis and mitigation plan, Cost benefit analysis, and ROI analysis.
  • Experienced in understanding database structures and write SQL.
  • Apt at writing Data Mapping Documents, Data Transformation Rules andData Dictionary maintenance, Data Migration, and Interface Requirements Documents.
  • Extensive management background within varied sectors of the healthcare industry including HMOs, PPOs, Integrated Hospital Systems, Out-Patient Surgery Centers, Dental, and Vision.
  • Strong knowledge of gathering requirements for Medicaid Management Information System MMIS session.
  • Thorough knowledge of HIX, PPACA and HL7.
  • Proficient in business requirement gathering and writing, including the EDI transaction from 4010 to 5010.
  • Detail understanding of ICD 9/ANSI/HL7 to ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare industry.
  • Extensively worked and presented several documents and Use Cases for multiple transactions including837I, 837P, 835, 276, 277, 270, 271 both inbound and outbound transactions for ongoing industry projects.
  • Good knowledge of Health Insurance Plans Medicare Part A, B, C and D , managed care concepts Medicaid and Medicare , and experienced in determining the membership eligibility, billing experience within life, and disability in health plans.

Technical Overview

  • Business Analysis MS Visio, Test Manager, Test Director, Win Runner
  • Project Management MS Project Server , Creative Pro Office, JIRA
  • Operating System Windows XP, Windows 7, UNIX, Linux, Mac OS
  • Languages C , Java, VB, HTML, XML, SQL, PLSQL, C , JavaScript
  • Application Microsoft Word, Microsoft Excel, Microsoft PowerPoint , Microsoft Access ,Visual Studio, Eclipse, Share Point
  • Database MS SQL Server, Oracle 8i, 9i, 10g, MS Access
  • Other Tools


Sr. Business Analyst / EDI Specialists

  • The project was ERRP Early Retiree Reinsurance Program .ERRP a provision of Patient Protection and Affordable Care Act PPACA , provides reimbursements to plan sponsors for a portion of the cost of providing health benefits to retirees between the ages of 55-64, and their covered dependents regardless of their age. This temporary program makes available 5 Billion to help employers continue to provide coverage to early retirees.
  • Worked as the First line of contact for the company regarding E-Commerce, EDI, and other B2B for customers, suppliers, and internal users.
  • Provided technical support assistance for customers which may include the identification of mapping issues, high level explanation of business processes, resolution of production problems, monitoring/researching of error reports/emails, and the reprocessing of data.
  • Analyzed trading partner specifications and created EDI mapping guidelines.
  • Gathered accurate and relevant incident information and Documented problems for escalation
  • Performed Quantitative Analysis for formatted MBD Medicare Database response files.
  • Identified Early Retirees, Completed Early Retiree list Setup, Formatted and Submitted Retiree List and Reviewed the Early Retiree Response File.
  • Updated and Reviewed ERRP EDI Processing Topical Training Manual
  • Third Level Review of ERRP Applications, Entered data into Master Spreadsheet and updated VIPs Assist.
  • Prepared Business Requirement Document BRD and converted into Functional specification and Non- Functionalrequirements
  • Conducted JAD session with the internal stakeholder to review high-level requirements
  • Coordinated the setup of new trading partners, including planning, project management, testing, documentation, and implementation.
  • Developed and maintained functional specifications for new / existing applications needed to maintain/enhance EDI processing and address the requirements of new trading partners.
  • Participate in transaction analysis and mapping needs, system / interface analysis, and work with programmers to implement changes as needed. Ensure that regulatory transactions and security standards have been met.
  • Preparing Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models and uploading documents in ReqPro.
  • Performed MBD check for response files Verified ERRP coverage by checking Medicare coverage dates .
  • Enhanced or developed new documentation of current business process flow and definition of future EDI business information flow.
  • Performing GAP analysis of business rules, business and system process flows, user administration and requirements to document the current as-is processes and the future to-be processes.
  • General process improvement input by attending conference calls and partner visits.
  • Responsible for managing relationships with the business units as well as interacting with software vendors and consultants for development and support.
  • Participated and coordinated the validation of the solution, regression testing, user acceptance testing, and training.
  • Developed and maintained documentation of all technical and procedural changes affecting the Specialist's area of responsibility.
  • Developed and maintained SOPs and operational procedures to follow good business practices and remain compliant with the governing regulations.
  • Responsible for the accuracy and timeliness of the daily processes of the organization's electronic data interchange systems, support of internal users, trading partners, testing and roll-out of related procedures
  • Environment - .Net, MS Excel, Java, J2ee, MS Visio, MS Access, MS Outlook, MS Power point, MS Word, MS Project, Rational Requisite Pro, OBIEE, Rational Clear Quest, SharePoint, Load Runner8.2.


Sr. Business Analyst

  • The project scope included ICD 10 Care Management Impact Analysis where care Management utilizes multiple software systems to support the intake and processing of authorization requests. The authorization requests are based on ICD 9 codes, which need to be replaced by ICD 10 codes to meet the mandate date.
  • Responsibilities:
  • Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers, and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements
  • Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, and Medical policy waves.
  • Conducted Impact analysis when there is any change in the requirements and updated the Business Requirements Document BRD , and Systems Requirements Specification SRS .
  • Experience designing financial applications that involve the utilization of Medicaid rates for a complex health related agency. ie. Rate Setting, Rate Distribution, or Billing .
  • Strong knowledge of Data Warehousing, and Business Architecture
  • Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD 10 such as EDI ClaimsIntake, Medical Management- Utilization Management, Case management, and Provider Reimbursement- Provider Payment.
  • Worked on Financial Analysis of DRG shifts from ICD 9 to ICD 10 to avoid any over or under payments to the providers.
  • Used General equivalence Mappings GEM to convert ICD 9 to ICD 10
  • Facilitated JAD and JRP sessions with management, development team, users, and other stakeholders to refine functional requirements.
  • Prepared use cases and data flow diagrams to analyze the impact of ICD 10 diagnosis codes embedded in different systems and applications.
  • Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements.
  • Used UML for Specifications, Documentation, and Construction of systems.
  • Designed and developed Business Rules Document about the Claim Component and HIPPA.
  • Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non-functional requirements.
  • Validated that the system claim scrubber included editing based on the CEM published edits to ensure a positive 999 and 277CA transaction.
  • Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
  • Designed robust 5010 testing and 4010 regression SIT and UAT Testing Scripts for the 5010 Project.
  • Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis and expected results for 5010 compliance.
  • Documented workflows and executed comprehensive testing and training plans to ensure that the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
  • Took action in the process flow to prevent rejected claims from falling into limbo . Mitigated claim denial increase through a complete analysis of the application Claims Scrubber to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.
  • Identified all risks associated with the project and proposed suggestions for mitigating the identified risk related to the business.

Environment: MS Project, MS Access, MS Excel, MS Word, MS Power Point, Rational Requisite Pro, Clear Case, Clear Quest, RUP, Share Point, Java, J2ee,


Business/ Quality Analyst

The scope of the Nebraska Medicaid Management Information System MMIS HIPAA 5010 Electronic Transaction Standards and National Provider Identifier NPI project includes remediation of the legacy MMIS to meet the minimal functionality necessary to electronically send, receive, and process the HIPAA compliant standard transactions, and fully implement all components of NPI.


  • Analyze 4010 Companion Guides and define NE Medicaid HIPAA 5010 Companion Guide Approach and Design.
  • Analyze and document NE Medicaid impacted areas for ICD 10 codes sets.
  • Analyze impacted HIPAA Transactions for process changes with ICD 10 implementation.
  • Identify and document changes in coding definition, conventions, and guidelines between ICD 9 and ICD 10.
  • Involved in one-to-one interview sessions and JAD sessions with stakeholders, SMEs,and business owners to discuss the scope of the conversion.
  • Responsible for documenting As-Is and To Be systems.
  • Facilitated JAD sessions with management, development team, users, and other stakeholders to refine functional requirements.
  • PreparedBusiness requirement Document BRD and functional requirement document FRD for the enhancement of the existing services.
  • Analyze and document HIPAA Trading Partner Application changes for HIPAA 5010 Implementation.
  • Responsible for attaining HIPAA EDI validation from Medicare, Medicaid, and other payers of government carriers. Developed Requirements Traceability Matrix RTM using Rational Rose to trace each software requirement to test case.
  • Designed the business requirement collection approach based on the project scope and SDLC Methodology.
  • Conducted requirement gathering sessions for MMIS Mainframe Claim processing screens.
  • Followed the Business Rules, and ensured that HIPAA compliant Rules are followed to display minimum benefit information that the Provider is required to pass on the EDI transactions.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
  • Worked on EDI transactions: 270, 271, 834, 835, and 837 P.I.D to identify key data set elements for designated record set. Interacted with Claims, Payments, and Enrollments hence analyzing and documenting related business processes.
  • Gathered requirements for 277CA Claims Acknowledgement which werenew for 5010.
  • Worked on requirements gathering for 997 and 999 acknowledgements.
  • Responsible for scripting HIPAA 5010 Implementation changes.
  • Interacted with Business analysts and developers for the requirement clarification.
  • Worked as an Interface between the users and the different teams involved in the application development for the better understanding of the business and IT processes.
  • Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates.
  • Responsible for developing and Executing Test Scripts for HIPAA Trading Partner Application.
  • Conduct User Training for 5010 changes for Trading Partner Application.
  • Responsible for Performing External Trading Partner Testing.
  • Environment: Data stage, Microsoft Windows Server system, Quality Center, Visual studio, ASP.
  • Net, Web services MS-Project, MS-Visio, and Windows 7, Power Builder 12, UltaEdit-32
  • Professional, IBM Mainframe, SQL, Oracle 9i, File Viewer, MS Office 2007, MS Visio, Office
  • Communicator, Lotus Notes, WebEx.


Business System Analyst

The project was to develop a Provider Desktop module for the EHR Electronic Health Record System with the objective to improve productivity and patient care. The system serves as a central dashboard for providers to access crucial information such as Patient appointments, Clinical results, Messages, Electronic lab orders, and Patient encounter notes anytime anywhere. The project was implemented securing patient privacy and health information conforming to HIPAA standards and guidelines.


  • Interacted closely with the Business users along with the administration and management to gather business requirements and analyze the functionalities to be incorporated into the system.
  • Attended demo sessions to understand existing system functionalities.
  • Followed the Agile methodology during the entire SDLC.
  • Formulated Data Mapping Guide for the technical team.
  • Coordinated with system architects and developers to convert business requirements into system requirements.
  • Facilitated JAD and JRP sessions with management, development team, users, and other stakeholders to filterfunctional requirements
  • Prepared the Business requirement Document BRD and functional requirement document FRD for the enhancement of the existing services.
  • Conducted meetings to document Change Requests for new requirements.
  • Analyzed business requirements and segregated them into Use Cases. Created Use case diagrams and documented Use case specifications.
  • Maintained various versions of the documents generated during the project using Rational Clear Case.
  • Was responsible for creating and updating project schedule and managing resources and timeline using MS Project.
  • Worked with the ETL development team to migrate the data from the old data mart to the new IDW Insurance Data Warehouse and to validate the data integrity.
  • Prepared the project status reports and represented the BA team in the PMO meetings.
  • Participated in UAT along with Business SMEs.

Environment: RUP, MS Visio, MS Project, MS Office Suite Word, Excel, Access, Power Point, Outlook , Rational Requisite Pro, Clear Case, Clear Quest.


Business Analyst

  • United Insurance Co. Delhi Limited is an ISO 9001:2000 certified insurance company. The company is promoted by leading industrialists and reputed trading and commercial houses of India. Worked on personal accident insurance claim services. Developed claim process application for the accuracy and proper integration with the database.
  • Responsibilities:
  • Involved in gathering, analyzing, and documenting business requirements and data specifications.
  • Involved throughout the business Solution Development Life Cycle SDLC .
  • Followed Agile with Scrum SDLC.
  • Created and reviewed business requirements, functional specifications, project schedules, and documentation.
  • Involved extensively in the inception phase for understanding the Scope of the Project, feasibility of the implementation, and definition of the risk factors involved in the project.
  • Conducted JAD sessions for communicating with all project managers, senior management, and other stakeholders.
  • Created Process Flow diagrams, Use Case Diagrams, Class Diagrams, and Interaction Diagrams using Microsoft Visio and Rational Rose.
  • Conducted meetings with business users and SMEs to identify and gather various functional and non-functional requirements.
  • Helped identify reports for decision support system and interacted with database designers and architect to gather the requirements for reporting.
  • Functioned as the primary liaison between the business line, operations, and the technical areas throughout the project cycle.

Environment: MS Access, MS office 2003, MS Excel, Rational Rose, MS Visio, MS Office

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