SUMMARY:

• A result - oriented individual with over 10 years of diversified experience in Healthcare and Finance IT industry.
• Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.
• Extensive experience as Business Analyst in the Healthcare Industry with expertise in Affordable Care Act (ACA), HL-7, EDI Transactions (834, 835, 837), HIPAA, MMIS, Confidential and Medicaid.
• Experienced in business process flows, business process modeling, case tools, business analysis, gap analysis and organizational change management.
• Experienced in conducting sessions and worked with executives, developers, and end-users to define the exact requirements.
• Solid understanding of, Claims Processing, Billing, Benefit/ Eligibility, Authorization/ Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions (837, 834 and 820).
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS.
• Knowledge on Confidential, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, ICD-9, ICD-10, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.
• Used Microsoft SharePoint as a Web-based Content Management System as well as a Document/ Project Management tool.
• Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment).
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Confidential, Medicaid, CDHP (consumer driven health plans).
• Ability to develop business rules, context data flow diagram, entity relationship diagram, workflow diagramming, prototyping and document current state, gaps and future state processes.
• Experience in multi-tasking such as managing numerous simultaneous projects with great attention to detail.
• Experience in solution assessment, validation and applying critical thinking for problem solving approach.
• Experience in Requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.
• Comprehensive knowledge of Software Development methodologies (SDLC) such as Waterfall, Agile, Spiral and Scrum.
• Create various documents like the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS).
• Good Knowledge of software and applications designing tools for the preview of the project at the very beginning.
• Analyzed different types of Risks such as Credit Risk, Market Risk etc and developed the test scripts with all these parameters to analyze the securities.
• Worked closely with project Stakeholders, SMEs, PM, to understand, analyze, document, validate, and review the requirements and specifications for new applications along with enhancements to the existing applications.
• Efficient in writing Business Requirement Document (BRD), Functional Specification Document (FSD), Use Cases, User Interface Specifications (UIS), System Requirement Specification (SRS) and Report Specifications Documents.
• Skilled in translating business requirements and user expectations into detailed specifications and building business process flow charts using MS Visio and Enterprise Architect to communicate project functionality to the development team employing designing techniques like OOAD and Unified Modeling Language (UML).
• Sound proficiency in analyzing and creating, Use Case Diagrams, Sequence Diagram, Activity Diagram, Data Flow Diagrams, Business Flow Diagrams, Wire Frames and Mock-ups using MS Visio and Rational Rose to communicate business and functional requirements to clients and developers.
• Performed AS-IS and TO-BE business process flow for clear translation of Functional to system requirement specification.
• Support the Test Team and the rest of the Development Team in compliance related issues while working with them in the development phases of the projects.
• Business Analyst with solid understanding of Business Requirements Gathering, Business Process Flow and Business Process Modelling and Data Mapping.
• Extensive working experience on Medicaid, Confidential and MMIS projects.
• Capable of managing multiple projects simultaneously

TECHNICAL EXPERTISE:

Modeling Methodologies: Agile, Rational Unified Process RUP and Waterfall

Process/ Modeling Tools: Rational Rose, MS Visio, Lombardi

Databases: MS Access, SQL Server, SSIS SSAS SSRS

Quality Management: HIPAA, CMMI, CMM

Languages: SQL HTML, C, C

Operating System: WINDOWS 98/2000/NT/XP

Office Tools: MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, SharePoint

Project Management: MS Project

Healthcare Tools: Trizetto Facets 4.51, Claredi, Amisys, QNXT

PROFESSIONAL EXPERIENCE:

Confidential, Chicago, IL

Business Analyst

Responsibilities:

• Studied business requirements and conduced User Interviews to identify and document the data discrepancies and their sources as related to Government Contract Compliance GCC, Government Disclosures, Government Pricing, Customers, Products, Product pricing.
• Prepared Test Plans for each release, written Test Cases and executed them as part of Functional Testing. Prepared Test Reports and Deliverables and submitted for version releases.
• Worked on Re-engineering, Designing, Developing Implementing Medicaid Management Information Systems MMIS for State's Medicaid Program.
• Created the accumulation Rules in Processing System. The Blue Exchange Provider Tool - Enhanced Eligibility Iteration 4 EEI4 mandate requires Confidential to respond to the provider request for eligibility information HIPAA 270/271 with accumulation amount.
• Incorporated Rational Unified Process RUP to create Requirement Document Specifications using Visible Analyst.
• Worked on Re-engineering, Developing Implementing Prior Authorization Web Systems/Applications interfaced with MMIS
• Set claim processing data for different Facets Module.
• Tested HIPAA regulations in Facets HIPAA privacy module.
• Tested and delivered Inbound/Outbound Facets interfaces.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Enhanced test cases using GUI checkpoints, Database Checkpoints, Text checkpoints and Bitmap checkpoints
• Data Warehouse application development, support and maintain activities using Microsoft SQL server, SSIS, PL/SQL, Oracle database technologies
• Understanding of the practices and methods of Business Process Re-engineering.
• Experience in testing HIPAA EDI Transactions.
• Worked with in the areas of Clinical, Corporate and Finance, Pharmacy, Sales, Provider Network and identified the use of ICD 9 codes and prepared documents for the conversion of ICD 9-10 and vice versa.
• Conducted JAD project team and came up with the best solution to setup Accumulation Rules in the system.
• Used gap analysis framework to identify AS-IS processes of claims transactions of HIPAA X 12 4010/4010 A standard and TO-BE processes ICD-10-CM and ICD-10-PCS compliance requirements of 5010 standards
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Performed impact analysis for deadliness of ICD-10 conversion.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process Pre-Adjudication.
• Worked intensively on FACETS 4.6.1 for audit trails made on the used account and check and store information related to the HIPPA authorizations.
• Wrote use cases, prepared use case diagrams using Rational Rose UML and followed Agile at every stage of the processes.
• Developed the business crosswalks for 837 P, I, D, 835, 834, 270, 271 and 276/277 according to HIPAA implementation rules.
• Conducted user interviews, gathering requirements, analyzing the requirements using Requisite pro.
• Responsible for customer interface, requirements definition, general and detailed design, testing, maintenance and programs and managed requirements using Rational Requisite Pro.
• Conducted analysis of HIPAA compliance and took part in discussions for designing the healthcare transactions to be HIPAA 5010 compliant.
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Provider inquiry about the status of claims. This involved checking the MMIS claims subsystem to see the status of claims sent and informing the providers if the claims have been suspended / denied or paid.
• Played key role in defining test automation procedure and standards, creating Win Runner and QuickTest Professional scripts for all the modules, which reduced the regression cycle drastically and improved the testing efforts for daily builds.
• Using Dynamic SQL statements constructed and executed dynamically during run time, based on supplied users.
• Established a RUP Rational Unified Process centric business analysis methodology.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Deployed Map Viewer and Integrated Map builder with OBIEE by creating the Spatial Data in database and Created different Maps using Different Themes, Colors and Markers.
• Planned and defined system requirements to Wire Frames with Use Case, Use Case Scenario and Use Case Narrative using the UML Unified Modeling Language methodologies.
• Evaluated testing results for each potential release build using Test Director, Quality Center and Bugzilla reports, listing summarized bug information in priority sequence, recommended viability of release for production

Confidential, Minnetonka, MN

Healthcare Business Analyst

Responsibilities:

• Played an active and lead role in gathering, analyzing, and writing business requirements.
• Project was implemented in phases, enabling system to deliver as many business requirements as early as possible.
• Involved in Requirement Scoping and analysis of high priority requirements for implementation.
• Worked on Transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
• Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
• Evaluated Confidential requirements and benefits in Confidential Health Plans for member enrollment and management.
• Coordinated, implemented and provided on-going support of the Quality Performer as outlined in the Specifications Manual for Confidential Group Inpatient Quality Measures Centers for Confidential & Medicaid Services (CMS).
• Used HP Quality Center for writing Test plans and Test Cases.
• Worked on documenting business rules to be defined in the business rules management engine (IBM ODM).
• Participated in requirements meetings, writing requirements in CaliberRM, converting requirements from Caliber RM to HP Quality Center.
• Working knowledge of implementing software development projects using methodologies such as Waterfall, RUP, and Agile Scrum.
• Used HIPAA guidelines and regulations to keep track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.
• Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project.
• Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
• Developed Software Requirement Specification (SRS) document using Visio and MS Office.
• Loaded the defects on to HP Quality Center and maintained a track record of the updates on the defects from the development team.
• Executed Test Cases Manually, once the application is stable and documented the successful or unsuccessful completion of each test case in HP Quality Center (QC) for End-to-End Scenario based testing.
• Worked on Agile SDLC during the project phase, performed the role of Product Owner and Team member in Scrum Meetings.
• Participated in agile process - planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iteration.
• Involved in Testing Out-Bound Transactions (835 Health care claims Payment, 277 Claim Status Response).
• Consulted with healthcare third-party administrator company to develop conversion specifications for member, enrollment, and authorizations.
• Involved in Scrum development process and prepared Sprint burn down chart, product catalog and sprint backlog contain Business Requirements and supporting documents that contain the essential business elements and definitions as well as the tasks to be completed.

Confidential, Detroit, MI

Business Analyst

Responsibilities:

• Responsible for executing Epic workflow / flow sheet analysis, system setup and configuring Epic ambulatory and inpatient templates according to the specialty clinic patient order sets.
• Acted as primary liaison between the client departments and the Information systems IT department; performed analysis, review, and estimation of client requests.
• Tracked the day-to-day activities, responsible for new requirements and enhancements associated with EMR system.
• Worked with ANSI X12 4010 including medical transactions such as 837 (medical claims), 835 (medical claim payments), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), 277 (claims status response), 820 (enrollment).
• Performed project assignments, scheduling and tracking.
• Utilized Agile software development processes.
• Facilitated JAD sessions with all levels of the business community for requirements gathering, project development, design considerations, impact and risk analysis.
• Worked in various technologies such as EpicCare Ambulatory, EpicCare Inpatient, Citrix, HL7 (v 2.3/2.4), PACS, DICOM, XML, Java, .Net, Oracle and HTML.
• Aligned requirement documentation with use of UML for object-oriented software development.
• Ensured that each test case was documented with expected results and actual results. Documented errors and bugs on an issue log. Worked with the developers to ensure that issues were understood and corrected in a timely manner. Once issues were resolved, processed test cases again to validate that the errors and bugs were fixed. Processed weekly status reports showing status of all test cases. Once implemented, assisted end user to ensure functionality.
• Incorporated HIPAA standards, EDI (Electronic data interchange), and code sets, ICD-9 /CPT.
• Responsible for mentoring new team members.
• Assisted with unit and integrated testing efforts.
• Testing of Epic billing reports (hospital billing and insurance billing) for Epic billing output and interface accuracy.
• Create and execute revenue cycle medication Epic billing data and reports from decision support and billing systems. Analyzed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed.
• Ensure that data interfacing into the application meets business needs - both for ongoing interfaces and one-time data conversions.
• Liaised with end users on system design challenges and ps in relationship to clinical processes and procedures; presented these findings to application. Development team, making recommendations according to billing workflow and end user needs.
• Provided rotational 24X7 on-call revenue cycle and billing applications technical application support.
• Troubleshoot and track issues and problems related to Epic ambulatory care solution and inpatient management system. Developed Epic patient billing representative manual, provided new hire operational and application .

Confidential, Tampa, FL

Business Data Analyst

Responsibilities:

• Performed requirement gathering & analysis by actively soliciting, analyzing customer requirements and prepared the requirements specification document for the application.
• Involved in gathering reporting requirements from the business users. Involved in building data warehouse application,
• Developed information cycle diagrams, data flow diagrams, in MsViso.
• Writing data mapping documents, data transformation rules and maintaining data dictionary, data migration and interface requirements documents. Able to update Microsoft share point portal with the updated project documentation.
• Created logical data modeling using tools like CA ERwin data modeler
• Able to analyze and Map source to target mappings using client Tool CDMA (Code and Data Mapping Application) to further develop enterprise data warehouse for Blue Cross Blue Shield.
• Applying Master Data Management (MDM) concepts for data alignment, maximizing analytics and business intelligence promoting corporate objectives and initiatives
• Performed data analysis and ETL techniques for loading high volumes of data and smooth structural flow of the data.
• Experience in gathering reporting requirements from the business users for business intelligence.
• Updated requirement documents as per business user feedback and changes, involved in generating test plans and test specifications as per business requirements
• Involved in conducting manual and automated testing at various phases of the project development.
• Prepared test data for positive and negative test scenarios as per application specifications and application requirements and wrote test plans.
• Manually performed integration and build verification testing.
• Knowledge in relational database concepts like tables, primary and foreign keys, views and referential integrity. Proficient in the data manipulation using SQL for the retrieval of data from the relational database.
• Responsible for defect tracking and reporting. Participated in the bug review meetings.

Confidential, Indianapolis, IN

Business Analyst

Responsibilities:

• Gathered Business Requirements, interacted with the Users, Designers, Developers, Project Manager, and SMEs to get a better understanding of the business processes, and analyzed and optimized the process.
• Actively involved in the entire Software Development Life Cycle (SDLC) process.
• Created reports containing all the information regarding the publishers, distributors and retailers using crystal reports.
• Facilitated demonstration of a major ACH software systems and performed evaluations with a group of experts to select a package that best suits the need of the business.
• Extensively worked with HIPAA transactions such as 835-claim payment/advice.
• Developed traceability Matrix for maintaining/updating current and new system requirement using MS Excel.
• Researched/Analyzed the various steps claim processing lifecycle and then wrote the Business Requirement Document and Functional Requirement Document in such a way that developers could construct the system to identify and monitor the riskier claims.
• Worked with electronic claim clearing house like Web M and automated clearing house (ACH) for electronic payment, remittance data processing and services.
• Created the User Requirement specifications and helped convert them to Functional Requirements and assisted the developers with System Requirement Specifications.
• Responsible for ensuring data integrity and coordinating effort with testing and implementation responsible for the development and execution of test plans.