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Edi/business Analyst Resume

New York, NY


  • 7+ years of Business System Analysis experience with in - depth knowledge of Software Development Life Cycle (SDLC) and business processes in Health Care Sector.
  • Specialized experience in healthcare insurance domain including Medicare, Medicaid, PBM, Procedural Diagnostic codes and Claims Process. Profound experience with HIPAA X12EDI transaction codes such as 270/271 (inquire/response health care benefits and eligibility), 276/277 (Claim-status), 278 (Transmitting health care service information), 834 (Benefit-enrollment), 820/835 (Payment/remittance advice), 837 P/I/D (Health care claim).
  • Proficient in Requirement Management, including gathering, documentation, analysis, detailing and tracking requirements mainly in health sector.
  • Good understanding of SDLC and have worked on different methodology such as Agile, waterfall and RUP.
  • Experienced in documenting requirement using Unified Modeling Language (Use Case and Activity Diagrams). Also building business Process Flow, Context Diagrams, Sequence Diagram, Activity Diagrams, Class Diagrams using Microsoft Visio.
  • Expertise in Enrollment, Claims, Subscriber/Member, Plan/Product, Provider, and Billing Modules in Facets.
  • Strong knowledge in Web Services, n-Tier SOA Architecture using SOAP, REST and FIX APIs. Strong understanding of XML, JSON and FIXML messages; Responsible for API documentation using MS Excel.
  • Experienced in Process Modeling (activity, state, object, sequence, class) using UML, UMM, and BPMN notations.
  • Expert in Healthcare Payer systems - Claims, Billing with backend data mapping, data integration.
  • Involved in Facets Output generation, Interface development and Facets Modification Projects.
  • Provided analytical solution to the customers for Facets Production Issues.
  • Experience conducting User Acceptance Testing (UAT) and writing test cases for the same.
  • Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing/Enrollment.
  • Experienced in interacting with business users to identify their needs, gathering requirements, developing detailed functional specs through JAD sessions, interviews, on site meetings and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project.
  • Extensive hands on experience in creating RTM, Defect Status Report, Change Request Form, Test Plan and Collaboration Diagram and designing User Interfaces (GUI) and wireframes.
  • Knowledge and expertise in working with Claims, Provider, Enrollment, Finance, Benefits, and Vendor Management Business Areas.
  • Possess a detail-oriented nature with excellent communication, interpersonal and organizational skills. Recognized for being a valued team player with ability to multi-task.
  • Strong command in converting client’s non-technical requirements to precise technical representation to the team. Experienced in dealing with cross-functional team environment.


Project Methodologies: SDLC, RUP, UML, Agile, Waterfall

Business Modeling Tools: Microsoft Visio

Languages: HTML, XML, JSON, Java and COLBALT

Testing tools: ALM Quality Center, REST

Change Management Tools: Rational Clear Quest, SharePoint

Office Tools: MS Project, MS Office, MS Visio

Version Control Systems: Rational Clear Case, SAFE, CVS

Database: MS SQL Server, MS Access, Mainframe and Oracle


Confidential - New York, NY

EDI/Business Analyst


  • Analyzed business requirements and module-specific functionalities to identify test requirement
  • Developed Requirements Traceability Matrix to track requirements.
  • Creating technical specifications and test plans. Testing the REST endpoints using Swagger UI or Postman for confirming the working of functionality that matches the requirements.
  • Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication)
  • Produced Business Requirements Document (BRD), Functional Requirements Documents (FRD), Impact Analysis Document and Requirements Traceability Matrix (RTM).
  • Worked with developers in debugging efforts for mobile application and tracked defect in TFS.
  • Perform comprehensive analysis of any error using the logs, json, database etc., debug and record issues in a defect tracking tool.
  • Managed RTM and tracked requirements status throughout the project. Also managed changes to baseline requirements through effective application of change control processes and change management tools.
  • Validated business requirements by facilitating JAD sessions.
  • Worked with different data sources non-relational databases such as Flat files, XML files, and other relational sources such as Oracle, MS SQL Server, MySQL and DB2.
  • Assisting UAT with case setup and providing walkthrough for the test plans.
  • Managed test file trading with external trading partners (clients/payers, providers, clearing houses).
  • Performed manual testing by building 837 claims, converting them into EDI file, uploading them into mainframe region and doing error resolution & testing for requirements.
  • Creating ad-hoc reports for various internal and external business clients.
  • Data analysis for bug fixing and/or new requirements.
  • Facilitated JAD sessions with the business group (traders and portfolio managers) to gather, analyze and document business requirements and business rules.
  • Responsible on creating user stories in an Agile Scrum framework in scratch.
  • Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)
  • Created analytics dashboards. Captured and consolidated key metrics.
  • Managed database design and implemented a comprehensive Star-Schema with shared dimensions.
  • Validating and profiling Flat file data into Teradata tables using Unix Shell scripts.
  • Have worked on SAFe Agile methodology and created user stories, User Stories refinement (Story elaboration) and User Story acceptance after successful demo by Dev/Test team.
  • Monitoring and tuning data loads, monitoring performance, communicating functional and technical issues.
  • Owned and executed UAT phase of SDLC including kickoff meeting, fielding questions, entering defects into HP Application Lifecycle Management (ALM).
  • Provided business requirements within Waterfall software development environment.
  • Used SQL queries to extract data from different databases including testing and production for data validation and data analysis.

Confidential, Durham, NC

EDI/Business Analyst


  • Communicated business priorities to the organization to effect business solutions.
  • Created and maintained BRD to assist Business PM close basis while managing multiple Claims projects.
  • Practiced in full facing AGILE methodology with SCRUM Meeting, Sprint Planning Meeting, Sprint Review Meeting, and Retrospective Meeting etc.
  • Converted Business Requirements to the Functional Specification.
  • Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams thus defining the Data Process Model and Business Process Mode.
  • Created UAT plans with several test cases for each project to ensure that the system runs smoothly after the proposed enhancements or changes have been made.
  • Created and maintained the Requirements Traceability Matrix (RTM).
  • Conducted JAD sessions to gather and document requirements that enhance a wide range of functionalities including Claims processing, eligibility and enrollment, provider networks, and electronic data interchange for our Facets core application.
  • Dealt with the EDI transaction claims payments and remittance advice, which deals the payment from payer to provider.
  • Facilitated meetings among the Change Management, Problem Management and other relevant teams to discuss the impact of the changes, problem tickets and prepare project milestone plans.
  • Gathered requirements and developed Process Flow diagrams in accordance with CareFirst and Medicaid business rules and regulations pertaining to the Facets configuration and evaluated the impacts of proposed changes.
  • Implementation of Agile, Scrum, SAFe Lean best practices and processes.
  • Involved in Sprint planning sessions to identify the features and functionalities that should be achieved by the new application. Identified various points of integration among the new and existing applications and required integration with other IT components.
  • Involved in testing Web services(SOAP and REST) and XML using SOAP UI for the local WSDL / with URL and created Test cases and execute them.
  • Responsibility included creation, member enrollment, billing, letter generation, contract administration and claim adjudication.
  • Reviewed extensive SQL Queries with complex multi-table joins and nested queries
  • Analyzed the Application to scope out errors after submittal of transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment), 276-277 (Claim status), 834 (Enrollment), 270/271 (Member eligibility).

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