SUMMARY:

• 8 years of experience working as a Sr. Business Systems Analyst in Health Care domain.
• Strong knowledge of applied principle of the iterative methodologies of Software Development Life Cycle SDLC including Feasibility Study/Gathering Requirements, Analysis/Design and Development, User Acceptance Testing UAT , Implementation and Post-Implementation Validation.
• Expertise in HIPAA Testing Privacy with multiple transactions exposure such as Inbound Claims 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions and testing in Client Server systems and Mainframe Applications.
• Experienced in facilitating Joint Application Development JAD , Rapid Application Development RAD and Joint Requirement Planning JRP sessions, interviews, workshops and requirement elicitation sessions with end-users, SME's Subject Matter Expertise , clients, stakeholders and development team.
• Well
• Experience in data mapping of HIPAA 4010 codes to HIPAA 5010 codes and ICD 9 codes to ICD 10 codes.
• Familiar with Claim, Member, Provider, and Appeal/Grievance setup on FACETS.
• Experienced in interacting with business users to identify their needs, gathering requirements and authoring Business Requirement Documents BRD , Functional Requirement Document FRD and Software Requirement Specification SRS across the deliverables of a project.
• Expert-level experience in writing SQL queries for data retrieval and management.
• Excellent knowledge of Medicare Part A, B, C and D and Medicaid Health Insurance Policies, worked using Maintenance Management Information System MMIS for claims processing and information retrieval.
• Good knowledge of Health Level Seven HL7 and Health Insurance exchange HIX plans.
• Well versed in EHR/EMR's and Emergency Medical Treatment and Active Labor Act EMTALA
• Proficiency in creating Business Process Modeling including Use Case diagrams, Activity diagrams, Sequence diagrams, Collaboration diagrams, Data-Flow diagrams using UML Methodology, in MS Visio and Rational Rose, as crucial project deliverables.
• Professional experience in writing Test Scenarios, Test Conditions, Test Cases and Test Scripts for Functional and Regression Testing based on the Design Document and User Requirement Document for the Functional, Security, and Performance Testing.
• Working knowledge of Change Notification Request CNRs Processes.
• Good understanding of Patient Protection and Affordable Care Act PPACA/ObamaCare and Health Care Reform.
• Strong knowledge of Health Insurance Plans like Health maintenance organization HMO , Point-of-service POS and Preferred provider organization PPO .
• Managed complex business initiatives to balance requirements for functionality, efficiency and quality.
• Excellent communication and presentation skills.
• Professional with extensive experience in the development, implementation and integration of strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills.
• Creative person capable of forming and maintaining positive and productive team environment, highly developed planning, management, problem solving and decision making capabilities.

WORK EXPERIENCE:

Confidential

Business Analyst Consultant

Project Description

Implement Regulatory and Operational reports for Medicaid State of Kentucky and Kansas Health Homes as part of funded projects of Enterprise Report. The Project goal is related to provide requested reports and provide necessary support until transition to the Health Plan.

Responsibilities:

• Work on analyzing assigned reports to identify related Global Business Rules.
• Arrange and conduct meetings with Business Owners and SMEs to define the requirements.
• Prepare the Business Requirement Document BRD and Technical requirement document to ensure requirements will be incorporated into system design and testing.
• Analyze complex end user needs to determine specific business application software requirements.
• Develop project plans and identifies and coordinates resources, involving those outside the unit.
• Full support by acting as a resource to users of the software to address questions/issues.
• Liaison between the Business needs business users and sponsor and the Technical solutions development and testing staff , ensuring technical solutions satisfied business requirements.
• Developed business requirement updates while working with different user groups to define priorities concerning project development.
• Documented business requirements, and communicated these requirements to the development team for the design and implementation of business solutions.
• Conducted brainstorming and JAD sessions with stakeholders and end-users for requirement analysis and documented the same
• Analyze and solve multi-dimensional challenges of Kentucky State required Appeal/Grievance categories.
• Associated with full life-cycle of Enterprise reports from Request Evaluation until UAT approval.
• Involved in writing test plans, defining test cases, test scenarios and data sets maintained test scripts, analyzed bugs and interacted with development team in fixing the errors.
• Analyzed, coordinated, documented and managed project requirements, project processes and procedures and its changes throughout the software development lifecycle.
• Manage to control all requested reports' modification after their implementation without a single breakdown.
• Worked with Subject Matter Experts SME , project team members business and technical , to define business and system requirements.

Confidential

Sr. Business Systems Analyst

Project Description

This project mainly involved in bringing Aetna's systems and business process in compliance with the HIPAA transaction standards. The project goal was related to the transition from HIPPA EDI X12 4010 to HIPPA EDI X12 5010 format. My responsibility was also associated in making changes from ICD-9 to ICD-10.

Responsibilities:

• Work on analyzing claims processing application in order to gather requirements to comply with HIPAA 5010 requirements
• Prepare the Business Requirement Document BRD and Functional Requirement Document FRD for the enhancement of the existing services.
• Engage in GAP Analysis workshops to facilitate requirement strategies.
• Conduct JAD sessions with business units and stakeholders to define project scope and identify the business flows.
• Formulate Data Mapping Guide for the technical team.
• Develop Data Flow, Work Flow, Process Flow, and Entity Relationship Diagrams in MS Visio, and analyze them to create AS IS and TO BE scenarios.
• Analyze HIPAA EDI 4010 and HIPAA EDI 5010 standards for 276/277transactions and prepare gap analysis document for each X12 transaction.
• Interact with the developers and involved in walkthrough meetings with them.
• Track project progress using Requirement Traceability Matrix RTM using MS-Excel
• Develop Use Cases using UML based on the needs of Business Users. Use MS Office for project tracking, documentation, and presentation
• Administer all provider enrollment transactions and managed new provider affiliations and terminations
• Manage and answer all questions from staff and provide status reports of all enrollment transactions.
• Support the QA team in preparing the test plan, test scenarios and test cases to be used in manual testing based on business requirements and simultaneously support on tracing the requirements in relation to the test cases.
• Strong Knowledge in writing test cases and test scripts as per the requirement and conducted User Acceptance Testing UAT with clients.
• Use the mapping tools to map 4010 and 5010 transactions along with ICD-9 and ICD-10 codes.
• Extensively use SharePoint for project documentation.
• Have worked very closely with the Quality Assurance and the Development Team

Confidential

Sr. Business Systems Analyst

Project Description

The objective of the project was to implement HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system. Also providers were able to automate tasks like Patient management, Accounts receivable management and collections, Appointment scheduling and recalls, Reporting, and Filing claims through EDI X12 format transaction sets in accordance with HIPAA standard.

Responsibilities:

• Employed Rational Rose to visually determine the proper structure, key elements and optimal design for database and to aid efficient creation of tables, stored procedures.
• Employed impact analysis, data analysis and risk analysis for User Acceptance Testing UAT .
• Strong Knowledge and understanding of ICD-9-CM and ICD -10-CM coding and claims processing. Also, well versed in Medicare Part A, Part B, Part C and Part D enrollment.
• Reviewed information gathered from multiple sources during requirement gathering and analysis and employed Rational RequisitePro for tracking, tracing and managing requirements
• Accountable for designing future state processes for HIPAA 5010 transaction processing EDI's 837 and 835.In addition Reviewed HIPAA 5010 related to 837,835, 834 Transactions and conducted gap analysis between HIPAA 4010 AND HIPAA 5010.Proficient in creating and maintaining Workflow plans and artifacts.
• Familiar with Facet processing system.
• Enforced an integrated RUP solution with complete line of traceability for all the artifacts of web development projects
• Employed MS Project for various planning and budgeting activities.
• Supervised, reviewed and model Test plans, Use Case Model cases Test procedures based on RUP methodology
• Wrote viable detailed user documentation and System Requirements Specification SRS documents with the purpose that developers could formulate application with minimum guidance
• Organized SWOT Analysis for better market understanding and fool proof project implementation
• Conducted UAT and registered test results according to the test plans using Test Director.
• Create Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models
• Supervised the functional aspect in accordance with the Business Process and validated the interfaces with the other systems and data conversion from the existing system
• Conducted Requirement Traceability Matrix RTM for requirement elicitation and linkup to deliverables
• Formulated Quality Assurance standard and processes for all levels of project team
• Conducted Gap analysis for the modules in production, organized feasibility study and conducted impact analysis for proposed enhancements
• Proficient in creating and maintaining Workflow plans and artifacts

Confidential

Sr. Systems Analyst

Project Description

The project Claims-Funds involved creating a new UI for better user experience in claim reimbursement process. Tennessee Department was used to view and modify claim fallouts that occur during claim adjudication process. Claim fallouts appear as a work item in Claim Processors Inbox, from where various actions such as claim adjudication, claim denial, claim reversal etc. could be performed.

Responsibilities:

• Gathered requirements and created BRD and FRD.
• Worked in Healthcare Claims Administration Healthcare Claims Processing 837/835 including the facility claims and professional claims.
• Involved in the day-to-day implementation of the Rational Unified Process RUP methodology of application development with its various work flows, artifacts and activities.
• Worked on HIPAA Claims Validation and Verification Process Pre-Adjudication .
• Worked on claim processing module which involved Receipt and Verification of Claim Forms 837 and Claims Attachments 275 , Claims Enquiry and Response 276/277 , Adjudication, Healthcare Claim Payment/Advice 835 as per HIPAA guidelines.
• Knowledge of the complete EDI format used in the electronic documentation which was part of the knowledge transfer program to the vendors as per the requirements.
• Assisted the UI architect in developing a new UI for the claims reimbursement process.
• Thorough understanding of the business process to help determine the user needs.
• Prepared Dataflow diagrams, Business Flow diagrams, UML Activity diagrams and Use Case diagrams.
• Performed GAP analysis and documented business and system level use cases to derive the requirements illustrating the functional behavior.
• Organized use case documents and developed RTM using Rational RequisitePro.
• Submitted change requests and worked with change request records in Clear Quest.
• Participated in entering, tracking system defects in Rational Clear Quest.
• Followed Six Sigma discipline and methodology for eliminating defects in process.
• Actively participated in the Weekly Defect Status meetings to review and prioritize the defects within a functional area.
• Involved in the different phases of test effort like Integration testing, Black Box testing, User Acceptance testing, Regression testing, and Back End testing.

Confidential

Sr. Business System Analyst

Project Description: The project was web-based application that gave providers online access to patient's records for more timely and accurate eligibility and benefits information of health plan offered by Citrus care.

Responsibilities:

• Elicited demands from the stakeholders and analyzed them for consistency, flexibility and completeness.
• Conducted JAD sessions with Subject Matter Experts to obtain domain level information.
• Involved in converting the User requirements into business requirements, functional requirements and technical requirements and also created business process modes from the requirement specification. Managed requirement using Rational RequisitePro.
• Presented and conducted functional requirement reviews and walkthroughs with the designers, developers, and stakeholders.
• Managed all the requirements in RequisitePro, creating a Requirements Matrix and making requirements available to all team members and also urge communication and collaboration among team members.
• Identified Use Cases from Business Requirements and created UML diagrams like use case diagram and activity diagram using MS-Visio for various stakeholders.
• Worked with HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
• Involved with the quality assurance team to develop and design test plan and test cases.
• Verified that the EDI transactions including 837 passed through six levels of testing as specified by WEDI/SNIP
• Involved in resolving and documenting issues related to these EDI transactions including 837 transactions using Test Director.
• Tested the final application for usability testing to verify whether all the user requirements were catered to, by the application.
• Managed change request and analyzed the impact of change request on the application in regards to Project Plan, Project Scope, and Project Schedule.

Confidential

Business Systems Analyst

Project Description

Project was to develop new software that will determine the eligibility of a Medicare recipient, processing Medicaid request forms, Medicaid claims, check if funds are available and also help staff into looking each costumer data to check eligibility of costumer for the Medicaid and help them best as possible.

Responsibilities

• Gathered Business Requirements. Interacted with the Users, Designers and Developers, Project Manager to get a better understanding of the Business Processes.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Liaison between the Business needs business users and sponsor and the Technical solutions development and testing staff , ensuring technical solutions satisfied business requirements.
• Performed Web Page Mock-Ups using MS Visio and thus defining the Business Process Model and Data Process Model.
• Developed gap analysis document, logical and physical design and remediation plan for State.
• Responsible for mapping documents, creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Worked with business owners, content staff, IT and other stakeholders in creating a content management solution for managing the information in the supplier portal using WebSphere Application Server.
• Built and customized SoDA for Word templates and extract information from information sources such as RequisitePro and Rose, and created a highly automated system for handling approvals, exceptions and priorities.
• Used the Rational Unified Process RUP to build the different phases of Software development life cycle.