SUMMARY

• With 10 years of experience in Business Analysis / Business System Analysis, business requirements modeling and development of Web Based, and Client/Server applications extensively in business domain of IT, Healthcare and Banking.
• Strong knowledge of managed care payer requirements,Operational improvements and procedures.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
• Extensive knowledge on FACETS Claim Processing, Pricing and Billing Processing between provider and payer.
• Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML).
• Developed customized SQL reports and queries for management decision - making and operational management.
• Vast experience in FACETs,Facets Data Model and Facets Tables.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Knowledge of the Back-End processes like Voucher Creation, EOB, Letter generation and 835 etc.
• Experience in development methodologies like RUP, SDLC, AGILE, SCRUM and Waterfall
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking
• Design and review of various documents including the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM) and testing documents.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.

TECHNICAL SKILLS

Rational Tools: Rational Rose/ Requisite Pro/Clear Case/Clear Quest/ SoDA.

Software Application: Adobe software application, Photoshop CS5, CorelDraw Graphics Suite X4.

Quality Management: Six Sigma, TQM, and Lean Manufacturing.

Operating Systems: Win XP/Vista/7, UNIX, Linux, SUSE, Mac OS.

Languages: C, C++, VB, .Net, Java, SQL, HTML, XML.

Databases: Oracle 11i, MS Access, Microsoft SQL Server 2005/2008.

Methodologies: SDLC, RUP, UML, JAD, CMMI, RAD, Waterfall, Agile.

Business Modeling tools: MS Visio.

Web Technologies: Microsoft FrontPage 2000/2003, HTML 09/2000, Dreamweaver 3.0

Other Tools: MS Office Suite, Caliber RM, DOORS, SharePoint 2.0 and iRise 5.

PROFESSIONAL EXPERIENCE

Confidential

Sr. Facets Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Extensive use of Facets back end tables and front end application system for data validation purposes.
• Used the requirement attributes (priority, effort, and risk) as the basis for negotiating the inclusion of the requirement, to manage the scope of the system efficiently.
• Complete daily claims and submit to payers (insurance, funds, and programs) for reimbursement.
• Analyzed data to confirm configuration. Retest changes, created test claims (DRG, referral authorizations). Systems: Facets, Amysis and QNXT.
• Enterprise level system processing EDI ANSI X12 835 Payer Remittance Transactions, Refunds, Transfers, and various other cash posting transactions related to insurance claims and patient account transactions.
• Perform research on Member, Provider, Claims, Authorization, Appeals and Grievances data from Facets back end and front end application system for reporting purposes.
• Analyzed on Facets 4.7 & Facets 5.0 Versions.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Processed 837P, 837I & 837D transactions, verified those 837 transactions converted correctly to XML file format & XC keyword file format and verified the claims data loaded to Facets & QNXT for further processing.
• Provided Production support, documented System Release/deployment issues & SOX documentation for Business Signoff.
• Developed Data Mapping documents for the 834 transaction sets for the EOB files to be generated Using FACETS 4.7 and 5.0 versions.
• Analyze change requirements for Providers, Contracts and Claims processing modules configuration in QNXT system for Medicaid and Medicare Advantage for AL, FL, GA, IL (ICP &MMAI), IN, MD, MS, NC, SC, PA and TN plans.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Did forward and backward data mapping between the fields in mainframe and FACETS.
• Enrolled members through online screens and 834 transactions to Facets & QNXT.
• Conducted Requirements walk- through with the Business Team to ensure that all their needs are met and gathered sign off on the requirements for SOX compliance after the requirements were base lined.
• Worked on developing the business requirements and use cases for FACETS batch processes; automating the billing entity and commission process.
• Prepared SOX documentation for business processes.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Captured the list of all the tables from Member/Subscriber modules in FACETS and all the dependent and related tables from other modules such as Claims and Providers for data mapping.
• Created dashboards using SPOTFIRE / Tableau catering to specific needs for different business groups.
• Tested the portal application to make sure the claims, members are loading to Facets & QNXT and Providers can check the member eligibility and claim status.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Developing TABLEAU based dashboards with appealing visuals that answers most of the businessquestions and indicates the next steps.
• Managed changing requirements which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Prepared and documented System Requirements and workflows for the Content Management Application tool.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Checked Business Readiness and determined activities of flow.
• Helped in writing Training manuals and helped business with the Training on a one to one sessions.
• Employed Rational Clear Quest for effective Change Management (Requirements Creep) and bug tracking during the testing lifecycle.

Environment: Rational Rose and Requisite Pro, MS Visio, Tableau, MS Project, UML, XML, SOX, Trizetto QNXT (Provider, Contract, Member, Claims Modules), Rational Clear Quest, Rational Clear Case, RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point.

Confidential, Harrisburg, PA

Business Analyst

Responsibilities:

• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify thebusiness flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Ensured all artifacts compiled with HIPAA 5010 policies and guidelines.
• Track and follow-up on all Medicare, Medicaid, and government programs, commercial and contracted payer issues; concentration on root cause analysis and resolution.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Responsible for verifying data integrity from several distributed systems to Facets system.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Performed the detail comparison between 4010A and 5010 to identify differences across loop structures.
• Did gap analysis for HIPAA4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
• Worked in Healthcare Claims Administration - Healthcare Claims Processing(837/835) includes Facility claims, Institutional and professional claims.
• Validating the 4010 and 5010 EDI 834.837 I, 837 P, 277U, 997,999 and 835 data in the QNXTApplication.
• Involved in developing database objects using FACETS database in both SQL server and Sybase environments.
• Worked extensively in HIE (Health Information Exchange) to facilitate access and retrieval of clinical data.
• Collaborated with External Auditors and documented SOX compliance requirements.
• Extensively involved in data validation between 834 Membership file to Facets backend tables and from Facets Backend tables to different external EDI extracts.
• Identify updates and/or changes to payer requirements prior to implementation and work with applicable Revenue Operations teams to ensure those changes are accurately reflected in all legacy systems; Proficient in medical billing.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems as well as for ICD 9 to ICD 10.
• Addressed all aspects of the claims processing life cycle, Studied and assessed the clients/patients systems and business processes. (HIPAA and SOX requirements).
• Used Erwin for monthly summary data marts and inventory data marts.
• Create SQL queries for product components to update FACETS backend tables, and create product prefixes.
• Conducted Business Requirements walkthrough with the business owners as well as the Technical Stakeholders.
• Participated in the monthly steering committee meetings to update the Business Sponsors on the project schedule and financials.
• Helped in the development and rollout of the ICD 10 Training and Curriculum Development Plan.
• Used Erwin for developing data model and forward engineer the data model.
• Keep up to date on coding information and that each payer receives accurate claims.
• Mentor lower level contract consultants and client's permanent QNXT Configuration Analyst.
• Extensively involved in writing the SQL queries to verify the data in the QNXT and online portal databases.
• Reverse engineer the data base in to physical data model by using Erwin.
• Worked on REDGATE to compare databases across the environments and compare the data and synchronize all database objects.
• Utilized Informatica to ETL data for business intelligence and reporting. Used Tableau as the reporting tool.
• Testing and validating the data for the various sub system within QNXT that could be made in the application. Used SQL developer and Toad for writing complex queries to verify data in QNXT tables.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Established Traceability Matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.

Environment: FACETS 4.71/ 5.01, HIPAA 4010/5010, EDI 837, 270, 271, Tableau, QNXT 4.6, QNXT 4.8, Quality Center, JIRA, MS Visio, Word, Excel, PowerPoint, SQL, .NET.

Confidential, DE

Business Analyst

Responsibilities:

• Responsible for requirements analysis, design and developing technical requirements.
• Championed Agile-related process improvements for all the phases of SDLC, participated in creation and deployment of Process Model for Agile SDLC (including templates, role definitions, description of phases, list of deliverables, etc.)
• Developed & analyzed current state business processes, workflow specifications and design parameters to identify gaps and risks to the future state roadmap.
• Created EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors.
• Created Mapping Documents, Report Mockups and modified existing report mockups as to CMS requirements and finalized for development.
• Completed conversion from Siemens Contract Management system to EPIC, building all contract terms for every payer including Medicare, Transplant, HMO, PPO, Medicaid and Tricare.
• Working with SME to design workflow and Use Case diagram, concerning IVR and Call Center Scripts for Medicaid Eligibility and Enrollment.
• Work with Compliance and Regulatory operations to follow and monitor different IT process bound by CMS Regulations.
• Developed business process models in RUP to document existing and future business processes.
• Performed extensive Requirement Analysis including data analysis and gap analysis.
• Incorporated Data Acquisition, Data Privacy, Data Analysis, Data Mapping and Data Compliance rules in the auditing criteria.
• Designed and developed project document templates based on SDLC methodology.
• Strong experience with different project methodologies including Agile, SDLC, RUP and Iterative Modeling.
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents.
• Conducted Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Monitor and analyze revenue cycle trends at payer and provider level on monthly basis.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release

Environment: Windows, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), SWOT analysis, GAP Analysis. Use Case diagram, Rational Unified Process (RUP, Mercury Quality Center).