SUMMARY

• Creative and innovative thinker, with excellent communication skills bringing energy, enthusiasm and leadership to problem resolution.
• Strong knowledge in Medicare, Medicaid, Facets, Claims, Medical Management and Policy Administration.
• Healthcare Payor Domain expertise: especially in areas such as Claims, Membership/enrollment, Provider/Network Management, Plan/Product, Customer Service.
• Conducting User Acceptance Testing UAT and familiar with testing tools to design and develop test plans and test scripts.
• Performing Gap analysis, Risk analysis, and risk mitigation.
• Worked closely with Business, SMEs and Solution Architects to assess requirements and specification of new applications and re-engineering of existing applications
• Effective communication skills and record for coordination between globally located teams.
• Demonstrated use of BABOK's Six Areas of Knowledge
• Functional experience includes Healthcare domain and strong technical skills in IBM Mainframe technologies.
• Clear understanding on EDI flat file renderings - FFRs, HIPAA, X12 transaction knowledge and expertise Application Developer/Business System Analyst.
• Overall 9 years of experience as a Business Analyst in analysis, design, development and testing of Health Care applications and in IBM Mainframe Technologies with complete understanding of Project Methodologies.
• I am a Certified Professional, Academy of Healthcare in management PAHM from Academy of Healthcare Management,Confidential.
• Demonstrated strong knowledge of ICD-9/ICD-10 and HIPAA 4010/5010 transitions in healthcare claims systems.
• Hands on Experience in ICD-10, HIPAA 5010, and EHR implementations and/or optimization projects.
• Experience in analysis, interpretation and reporting using medical or administrative data sets.
• Experience working with HL7 integration standards, Interface Engines, PowerShell and healthcare data.
• Understanding of ETL process best practices.
• Significant knowledge of / experience with major clinical, financial and transaction processing systems such as EPIC, McKesson, Cerner, SSI, etc.
• Conducted many Joint Application Developments JAD sessions, scrum meetings, walkthroughs, Interviews, Workshops and Rapid Application Development RAD sessions with end-user/clients/stake holders and the IT groups.
• Demonstrated knowledge in constructing, interpreting and modifying visual representations such as swim lane based process flows, ERDs, and data dictionaries.
• Strong business acumen, strategic thinking, communication, interpersonal and presentation skills adept at creating, editing, and coordinating extensive communication networks facilitation of JAD sessions and interviews, written correspondence, reports, implementation requirements, project status reports, oral presentations, e-mails, etc. to keep executive staff and team members abreast of goals, project status, and resolving issues and conflicts.
• Experience in conducting User Acceptance Testing UAT and considerable knowledge of Gap Analysis. Able to perform data analysis independently by building the required SQL queries without developer's assistance.
• Act as a liaison between business and systems during analysis, Development and testing phases.
• Modeling the system using Use Case Models, Analysis Models, Design Models, Implementation Models, authored Use Cases, Use Case Diagrams, Behavior Diagrams sequence diagrams, collaboration diagrams, activity diagrams based on UML methodology using MS Visio.

PROFESSIONAL EXPERIENCE

Sr. Business Analyst Order

Confidential

Project Summary

• Confidential is one of the largest Pharmacy Benefit Management organizations in the United States. The company processes pharmaceutical claims for members at network pharmacies and at their own mail order pharmacies. The scope of the project is to enable the members to have their prescriptions delivered to their home. Point Of Care is an application within Order to Cash, for entering a prescription into an automated data entry system, thereby generating a prescription electronically instead of handwriting the prescription on paper. This application handles all the prescriptions entered by the provider through automated data entry systems.
• As a Business Analyst, my responsibilities include
• Gathered requirements and prepared business requirement documents BRD .
• Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Prepared and presented the process of the ongoing project in a form of Dashboard to the senior management.
• Healthcare Business System Analyst and Developer in projects that constitute PBM, O2C, drug formularies and State Federal Law implementations.
• Developed and maintained all operational and technical flows using Visio and Power point
• Used MS Office Suite for creating use cases, workflows and sequence diagrams thus defining the Data Process Models
• Defined Use cases from requirements and helped convert them into software specifications
• Maintained Requirement Traceability Matrix RTM .
• Co-ordinate with the project managers in the preparation of the project plans with any impact due to a change request.
• Identified all the applications and interviewed the application owners to recommend the process improvements.
• Worked on adjudicating the pharmacy claims and Maintaining the claims control system for exception processing claims
• Performed Regression Testing and created test scenarios for User Acceptance Testing UAT
• Maintained documents for change request and implemented procedures for testing changes

Confidential

Sr. Business Analyst

Project Summary

• The scope of the project is to Configure and Enhance IT Systems to support new plans and products. Plan and implement data migration from existing claims engines COSMOS, DIAMOND to the new platform Community State Strategic Platform Claims and Eligibility platform on FACETS .To decommission the existing claims engines after the plan migration and to Execute the standardized functions for the core capabilities including Member Enrollment, Claims,Provider,Network set-up, Customer service, Portals for the new plans implemented on CSP.
• As a Business Analyst my role include
• Experience and implementation expertise on X12 4010 and 5010 standard transactions such as

o 270/271 Eligibility Transaction Processing

o 276/277 Claims Inquiry Transaction Processing

o 837I/837P Claims Submission Processing

o 278 Service Authorization Processing

o 835 Remittance Advice Processing

o NCPDP standard transactions

• Identified Use Cases from the requirements. Created UML Diagrams including Use Cases Diagrams, Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaboration Diagrams and Deployment Diagrams, Data Flow Diagrams DFDs , ER Diagrams and Web Page Mock-Ups using Rational Rose and MS-Visio thus defining the Business Process Model and Data Process Model.
• Designed SOA for the new functionalities in tool which will make the generic middle tier layer in the tool.
• Conducted JAD sessions for effective discussion between stakeholders and gathered business requirements.
• Communicated and interacted on a regular basis with the project manager and development team during different stages of the product life cycle
• Communicate with design, development and test team using MS exchange Messaging and Defect Tracking System.
• Ensured that all the artifacts are in compliance with corporate SDLC Policies and guidelines,
• Prepared BRD and converted into functional specifications using requirement management tool
• Created UML diagrams such as use case diagrams, and sequence diagrams
• Designed Data Flow Diagrams DFD's and Entity Relationship Diagrams ERD's using modeling tools.
• Prepared Business Process Models that depicted modeling of all the activities of the business from the conceptual to procedural level.
• Used the Unified Change Management UCM tool, Rational Clear Quest, to maintain and track the Stakeholders requested enhancements and changes.
• Used prototypes to demonstrate and verify the behavior of the system
• Provide technical and procedural support for User Acceptance Testing UAT

Confidential

Sr. Business Analyst

Project Summary

• Confidential is an end-to-end claims processing application based on IBM mainframe system and this projects mainly deals with the ASO line of Business which is a typical arrangement with Clients for TPA where UMR will handle the claims processing and administers the plans but does not pay for the claims and the claims will be processed against the Client's bank account. The end-to-end claims processing is done using the Trizetto product Claimfacts. The application subsystems include Hospital and Physician Claims Processing and Adjudication, Check and EOB generation, Member Enrollment, Provider Contract Systems, Accumulators, Provider Fee schedule loads and HIPAA gateway
• As a Business Analyst for the project my roles and responsibilities include
• Gathered requirements and prepared BRD, FRD, UseCases, Non- Functional requirements through JAD and brain storming sessions.
• Planned sessions with Business, SMEs and required stakeholders to confirm business requirements.
• Identify the various files Daily Transaction File, Customer File, and Non-Financial Activity File and reports created by the current Variable Annuity System with the help of VAS management team.
• Defined Use cases from requirements and helped convert them into software specifications.
• Aided management in standardizing UI used to create copies of files for users of dependent systems.
• Maintained Requirement Traceability Matrix RTM .
• Used Rational Unified Process RUP as the Software Method. Analyzed and optimized the process, Prepared Business Requirement Document and converted them to functional and technical specification using the rational requisite pro.
• Tracking changes to Files and Reports that result from other projects in the program.
• Provide technical and procedural support for User Acceptance Testing UAT .
• Maintained documents for change request and implemented procedures for testing changes.
• Involve in discussions with solution and process designers to help them understand the requirements and prepare robust solution and process design.

Confidential

Sr. Business Analyst

Project Summary

• Confidential Integrated Computing Environment is an end to end system for the health insurance organization which has the following core areas and subsystem.
• Providers, Employers, Contracts, Rates, Membership, Billing, Authorizations, Eligibility, Claims, Encounters, Capitation, Sales and Marketing, Data Warehouse Interfaces, Customer Service Interfaces, Accounting Interfaces, Broker Commissions, Voice Response Interface, Utilization, Care Management, Other Interfaces and Extracts
• As a Business Analyst, my roles and responsibilities include
• Broad range of experience working on different types of project like App development, Business Intelligence Workflow etc.
• Extensive scripting done in HP Quick Test Pro to automate Regression Testing.
• Planned sessions with Business, SMEs and required stakeholders to confirm business requirements,
• Defined Use cases from requirements and helped convert them into software specifications
• Maintained Requirement Traceability Matrix RTM .
• Provide technical and procedural support for User Acceptance Testing UAT
• Maintained documents for change request and implemented procedures for testing changes
• Involve in discussions with solution and process designers to help them understand the requirements and prepare robust solution and process design.

Confidential

Business System Analyst/ Developer

Project Summary

• Confidential is an AVM Application Value Management project involving the maintenance and enhancement of Confidential application. Confidential is an end-to-end claims processing application, based on UNISYS Mainframes. The application subsystems include Hospital and Physician Claims Processing and Adjudication, Check writing, Member Enrollment, Premium Billing, Authorization and Provider Contract Systems. Using this application, Unapprised Technologies serves United Health Care, and provides Third Party Administrator services to other insurance companies e.g. Medica .
• Responsibilities include:
• Understand the requirements and perform Gap Analysis.
• Assisted in technology selection for the application, based on Cost-Effectiveness and Quality with an eye towards the future.
• Understand the high level design and Prepare low level design document with pseudo code.
• Developed / performed coding on applications that involve major health care implemantations.
• Prepare unit test plan, system integration test cases and perform unit testing and system testing.
• Conducted Onshore-Offshore coordination calls for triage/status meetings.