- 10+ years of experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.) HL7, Eligibility and Benefit systems, HCPCS, CPT, HIPAA 4010 and 5010, Claims Adjudication and expert in Affordable Care Act (ACA), aka Healthcare Reform (HCR)
- Strong knowledge of SDLC methodology and project life and excellent Business writing skills in writing Business Requirement Documents Specifications, Functional Specification Documents etc.
- Excellent knowledge in Health Insurance, Health Insurance Exchange (HIX), Asset Management, Data Warehousing, and Human Health Services (HHS) environment
- Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrolment, 835 Claim Payments, 829, 270 - 278 and many other healthcare maps.
- Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare .
- Experience in Healthcare Application Facets in different modules like Claims, Membership, Provider and Billing.
- Wrote BRD, TSD, Mapping doc., test scenarios, test cases for testing the functional and non-functional aspects of both ETL and Reporting jobs.
- Expertise in Membership Enrolment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
- Proficient in conducting Business process modelling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis, SQL application management, (added users, created backup and recovery plans, ran SQL scripts)
- Experience with Health Cloud, Marketing Cloud, CPQ, and other specialized Salesforce modules.
- Extensive knowledge SDLC Processing in Agile, RAD (Rapid Application Development), RUP (Rapid Unified Process)
- Knowledge of medical terminology including CPT, ICD, HCPCS Codes and standard of claims processing guidelines
Methodologies: Waterfall, RUP, Agile (Scrum and XP), OOAD
Requirement Management Tools: UML, IBM Rational Requisite Pro, Power Designer
Project Management Tool: Microsoft Project 20019 and MS SharePoint 2019
Database: Oracle, SQL Server, MS Access
Testing tools / QA: Win Runner, Load Runner, Quality Center (Test Director), QTP
Business Modeling Tools: Power Designer, Rational Rose, Microsoft Visio, Smart draw, Concept Draw Pro, Justin mind Proto-type pro edition, Snipping tool, Serena change management dimensions.
Operating System: Windows 98/2000/XP/Vista/7/8/10, OS X, UNIX
Change Management Tools: Rational Clear Quest, Rational Clear case
Sr. Business Analyst
- Conduct “Business Requirements” meetings with clients to identify and document business requirements and converted them into System Requirement Specifications.
- Prepare Project Requirements Document and Design Information Systems Business Solution
- Worked on HIPAA 5010 compliance and EDI 834 transactions, ICD-9, ICD -10 Codes.
- Generated various SQL queries whenever required and worked on the documentation of the databases.
- Created Functional Requirement Specification Document which included UML, Use case diagrams, Scenarios, activity, work Flow diagrams and data mapping, and Data modeling with MS VISIO.
- Through understanding of Rational Unified Process (RUP), Unified Modeling Language (UML), and Rational Suite including Rational Rose, Requisite Pro, Rational Clear Case, Rational Clear Quest and Object-Oriented Analysis.
- Implemented Business Intelligence (BI) to help users make better business decisions.
- Conducted workflow, process diagram and GAP (GAP) analyses to derive requirements for existing systems enhancements.
- Proficient in creating Use Cases, Sequence Diagrams, Activity Diagrams, Class Diagrams etc.
- Involved in preparing a simple and detailed User manual for the application, for an intended user.
Sr. Business System Analyst
- The Project involved in developing and transition into the New CMS- 1500 (08/05 to 02/12) Form, setting up EDI Test Data Scenarios for the Internal Users.
- Located the 837 transactions and reports in the file that are in error and validate the data in the transactions.
- Dealt with the 837 and 835 ANSI X12 transaction understanding loops segments, elements and structure.
- Participate in User Acceptance Testing to ensure system corrections are accurate.
- Extract pharmacy claims, benefit and eligibility data for studies.
- Gather any necessary enrollment, formulary, pricing, benefit and trend information from internal departments and the PBM.
- Knowledge of pharmacy data (claims, fees, eligibility, benefits, formulary) and statistical analyses
- Extensively participated in verification of EDI file formats against Standards
- Designed and assisted in creating training material and conducting internal training sessions for business users who are using the functionalities of Salesforce technology.
- EDI healthcare experience working with implementation guides, TR3s
- Ensured that regulatory transactions and security standards have been met.
Technical Business Analyst
- Created and managed project templates, Use Case templates, requirement types and traceability relationships in Rational RequisitePro.
- Used the Unified Change Management (UCM ) tool, Rational ClearQuest to maintain and track the stakeholders requested enhancements and changes.
- Used Rational ClearCase, a Configuration Management tool, to maintain different builds of the application with description about all changes and versions.
- Design different custom dashboards and/or reports as per the user need for different user groups based on their business's functionalities and requirements.
- Created Use Cases using UML and managed the entire functional requirements life cycle using Rational Unified Process and Rational Rose.
- Assessed project status and tracked defects for quality control using Rational ClearQuest
- Responsible for preparing the Software Requirement Specifications (SRS) document, creation of Process Work Flows and Functional Specifications.
- Created product documentation including online help, printed user manuals, and training materials.
Business Data Analyst
- Created training materials, provided weekly training sessions, empowering users and creating successful outcome for relocation.
- Elicited requirements, outlined complex solution automating communication between 3 separate systems via data warehouse.
- Researched and managed implementation of digital signage solution in phases, meeting budget restraints and improving internal communications.
- Administered SharePoint intranet, including design and creation of cross - functional project sites, delivering consistent experience and ensuring appropriate access to shared content.
- Gathered requirements and designed online forms that improved efficiency and customer experience Created and analyzed Google Analytic reports for internal and external sites, identifying behavior patterns. Enhanced site design and timing of news postings, increasing views and engagement.