- Liaison between Business Systems and Information Technology with over 7 years of extensive Business Analyst skills - Understanding of Software Development Life Cycle (SDLC), Rational Unified Process (RUP),Agile/Scrum methodology, Unified Modeling Language (UML), Object Oriented Analysis and Design Concepts (OOAD), Business Process Re-engineering (BPR), Test Lifecycle, Data Modeling.
- Experience in writing Business Requirements Documents (BRD), System Requirement Document (SRD), Use Case Specifications, Functional Specifications, and Technical Specifications across the Deliverables of a project.
- Experience in handling Change Management and Release Management.
- Extensive Experience in UML and Process modeling using Use Case Diagrams, Activity Diagrams and Sequence Diagrams.
- Good experience in conducting Joint Application Development (JAD) sessions through interviews and workshops with subject matter experts and business users.
- Good experience with Rational Rose, Rational Requite Pro, Rational Clear Quest, Rational Clear Case, MS Project, MS Visio, Crystal Reports.
- Experienced in conducting GAP analysis, User Acceptance Testing (UAT), Risk Analysis and mitigation plan, Cost benefit analysis and ROI analysis.
- Experienced in various MS Windows platforms, OS, Office Suite, etc.
- Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277 and ICD9-ICD10.
- Extensive knowledge of Medical Management Information Systems (MMIS), Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process
- Capable to ensure raw Encounter Data received in various formats i.e; .CSV, XML, XLSX, Pipe-Delimited, .Txt were compatible with current logics, SP (stored procedures), UAI pulls and but not limited to CMS/AHCA Audits.
- Strong knowledge of Health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI), Implementation and knowledge of HIPAA code sets, ICD-9, ICD-10 coding,,HL7, HMO, PPO.
- 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. Excellent knowledge of HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
- Experience with Business Process Management.
- A motivated, committed, quick learning, detail-oriented team player with good communication, analytical, leadership, interpersonal and problem solving skills.
- 6 years’ experience in healthcare industry working with Encounter Data Submissions for Medicare and FL Medicaid.
Operating Systems: Windows, UNIX, LINUX, Mac
Languages: SQL, XML, VB, XRP EDI, ASP, Net, Assembly,HL7
Databases: Oracle, MS SQL server, MS Access, OPTUM, Facets Gateway
Tools: MS Office: Word, Excel,Csv/txt,Toad, Access, Power point, Project, Visio, Front Office, Rational Rose, SoDA, Edifecs, Tibco, Team Test, Doors, Clearcase, Clear Quest,, Web Sphere, Business Modeler, HP Quality Centre, Ultra Edit, Toad, SFTP\FTP\VPN\FTPS, Active Batch, JIRA, TFS,HPSM
Industry Standards: HIPAA, SOX, ISO, Six Sigma, CMM
Business Analyst / EDI System Analyst
- Developed business process artifacts (configuration design documents, process flow, work state diagrams, etc.) as they pertain to enterprise-level processes, spanning multiple functional areas. Documentation and implementations configuration and process improvements and control documentation.
- Conducted/ Facilitated / Set-Up secure transfer of information to and from outside vendors via FTPS, SFTP, or FTP and PGP encryption protocols with various data formats i.e; .CSV, XML, XLSX, Pipe-Delimited, .Txt
- Monitored/oversee scheduling of daily batch production jobs including job scheduling, maintaining accurate records of all production processing, problem resolution/escalation, and daily request QA environment test X12 segment validation processing.
- Create outputs to track the responses received for encounter data submissions ACK files; 999,277 and 835
- Engaged JAD sessions to create workflows for EDI validation by working with Third Party Management team (3PM) SNIP Level to ensure acceptance for member eligibility. Validated X12 Encounter Data through Edi-Fecs / Ramp. Coordinated sessions with Claims Team to review Raw (XML, XLSX, .CSV-.TxT ) results and ensure submission accuracy was met for AHCA, CMS submissions.
- This position main objective is to coordinate, implement, and manage all EDI-related developments for FACETs daily submission outputs and electronic case report objectives.
- Handle of transaction specifications in XML/X 12-837/270/999/835 formatting was reviewed with providers, users and team leads to coordinate Data Import for daily batch processing.
- Maintain raw Encounter Data structural value provided by businesses, stakeholders in various formats i.e; .CSV, XML, XLSX, Pipe-Delimited to create new SQL-Tables, Fields for user accuracy.
- Responsible for FACETS; New Encounter Data, Testing, writing the test scenarios cases for manual testing. Ensuring converted test KWD files routed to expected fields per Member demographics received via X12 format.
- Facilitate QA process with business users and helping them in execution of test cases. Create QA Data per the business and testing requirements to execute QA cases.
- Responsible for analyzing and designing specifications used for enhancements and extensions in EDI applications, interfaces, and mappings. Coordinate all EDI testing, and on-boarding.
- Primary link between LMCHP and data-trading partners, vendors, claims departmental users and, Clearing House configurations teams to establish analyzing the data exchanged with partners, observing data records to record any errors, and correcting any failures. Ensuring coding/logic developments made to Data-Base for both FACETS & SQL are configured to consume various formats received i.e.; .CSV, XML, XLSX, Pipe-Delimited
- Worked with employees at all levels of their organization to support accurate, proper data exchanges within the organization. Communicated any testing to observe and interpret messages received and offer updates to their supervisor.
- Developing and implementing X12 EDI distribution documents (including but not limited to 837, 999,277CA, 835, 834, 270, 271 to support Production.) as to distribute accordingly to clinical users and ensure raw data formatting compatibility with our tools manageable for any future automation requirements.
- Utilization of database queries (Oracle, SQL Server, and/or Toad).
Business Analyst / EDI System Analyst
- Create 837 (Professional, Institutional and Dental) files daily using TriZetto application Encounter Data Manager (EDM), validate the files in using AHCA’s edifecs tool Ramp Manager and submit the files to Florida Medicaid agency (AHCA) within SLAs
- Track the responses received for encounter data submissions (999,277 and 835)
- Research Encounter rejections which includes, identifying the root cause and sending the information to the operations team if rejection is a business error or work with hosting company Cognizant TriZetto if it is a system issue.
- Work with the business teams on new requirements or enhancements to the Encounter Data Manager (EDM) application.
- Create technical requirements of the transaction specifications in xml and x12 formats; 837(P, I, D) claims, and maintained data X12, XML, .cSV-.txt mapping documents in reference to HIPAA guidlines primarily 837(P, I, D), 834, 835, 270, and 271 in SharePoint, Jira, Confluence for team transfer knowledge.
- Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
- Working with Trizetto based software called QNXT to obtain members information for encounter / business validations.
- Test and deploy any code changes provided by TriZetto for EDM to ensure it meets the specifications and obtain sign off from the business team
- Working with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare and Florida Medicaid on a daily bases.
- Utilize SQL server to run basic queries and obtain necessary data for Medicaid and Medicare Encounters.
- Using SQL query to produce data for 270 EDI X12 file, and create 270 files and submit to MEVSNET to check dual snip member for Medicaid benefits eligibility.
- Review vendor files for any errors, missing segments, and for missing data on X12 file. Ensure file has complete data before encounter can be submitted to Medicare and Florida Medicaid.
- Analyzed Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
- Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 & 271HIPAA EDI Transactions using MS Word, MS Excel.
- Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifecs
- Worked with Trizetto to deploy required change requests to Production & QA
- Utilized Ramp Manager Application from Florida Medicaid to check X12 files for any error before submitting to Florida Medicaid.