SUMMARY

• An accomplished IT Professional with Seven (7) years of experience as a Business Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling.
• Experienced working on 4010 and 5010 HIPAA implementation guides relate to Claim Testing and Medical Billing
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
• Familiar with HIPAA Standards and Compliance issues, HIPAA Privacy policy, requirements gathering in compliance with HIPAA 4010 and 5010 standard.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum, RUP (Rational Unified Process) and Software Testing Life Cycle (STLC).
• Involved in GEM (General Equivalence Mapping) tools for forward mapping of ICD 9 - ICD 10 codes as required by the project.
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document (BRD) and Functional Requirement Specifications (FRS) document.
• Facilitated one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
• Experienced in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Involved in maintaining performing GAPanalysis, Requirement Analysis, Document Analysis.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277). Thorough knowledge about Facets.
• Proven ability to support multiple complex projects under tight deadlines, often with competing priorities.

TECHNICAL SKILLS

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management Tools: Rational Requisite Pro, Rational Rose, MS Visio, HP ALM

Operating Systems: Windows 2000/7/XP, DOS

Languages/Standards: SQL, HIPPA 4010/5010, ICD9/10

Methodologies: Agile, Waterfall

PROFESSIONAL EXPERIENCE

Confidential, Philadelphia, PA

Sr. Business System Analyst

Responsibilities:

• Submit and gain approval of EDI encounter transactions with TMHP (State of Texas)
• Worked with IT department to automate submission of transactions. The process includes importing claims into the revenue reconciliation manager that had been adjudicated and setting them to an ’02’ (Finalized) status so the claims can be sent to the reporting authority.
• Execution of weekly, bi-weekly, and monthly reports and the creation of adhoc reports.
• Help QA to test requirements to ensure proper development and deployment.
• Logging all CSV files, outbound 837 files and 999/277CA files.
• Checking Recon report daily to ensure that all claims were successfully made into outbound encounters for submission
• Created queries and reports to assist operations with the analysis of data relating to claims, members and providers.
• Worked with the implementation manager on various management activities like keeping track of project statuses and deadlines/milestones
• Co-conducted meetings with development team to discuss any requirement changes.

Environment: Windows 2000 /XP, Microsoft Office SharePoint, Rational Requisite Pro, MS Office, MS Project, SQL Server, MS Project, MS Visio, MS Access, EDI, HL7, UML

Confidential, Fort Worth, TX

Business System Analyst

Responsibilities:

• Submit and gain approval of EDI encounter transactions with State of Texas
• Worked on Facets including Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
• Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
• The process included importing claims into Facets that had been adjudicated and setting them in a "PAY" status so that a payment cycle could be run to create checks on Facets.
• Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure required interactions are met during the SDLC process.
• Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors with the process of EDI inbound and outbound files
• Validated outbound 835 transactions including but not limited with vendor on QNXT mapping and system configuration.
• Business Process Analysis/End User Education/Business Requirements Documentation
• Validated System configuration, including enrollment, provider, and benefits modules
• Creation of queries and reports to assist Health Plan Operations with the analysis of data relating to claims, members, and providers.
• Execution of daily, weekly, and monthly reports and processes and the creation of ad-hoc reports.
• Broad knowledge of CCHP departmental processes, procedures, and data.

Environment: FACETS, RUP, Rational Rose, Requisite Pro, MS Visio, RUP, MS Project, SQL, Oracle, MS Access, MS Excel, and MS Word.

Confidential, Jacksonville, MO

Business Analyst

Responsibilities:

• Prepared scope of the project and developed new business process along with process mapping and user task analysis. I also evaluated documentation analysis and business process analysis to identify the problem with existing system and find out new and advance way to develop business process, which was able to make the process more accurate.
• Worked on Facets including Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
• Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
• Worked with developing team to create advance claim submission process for Medicare and Medicaid patients as well as EDI transaction such as: 837 (P, I, D), 835, and 276/277.
• The process included importing claims into Facets that had been adjudicated and setting them in a "PAY" status so that a payment cycle could be run to create checks on Facets.
• Garnered information and knowledge to develop the transaction process that is more accurate and real time regarding 837 including HIPAA Government Regulatory Compliance and integrated the system with HL7 process.
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Conducted JAD session with business side to identify and gathered high level requirements and evaluated the priority level based on meeting discussions and comments on requirements.
• Developed a vision plan that defined the primary goals and objectives of the project. Analyze user stories and segregated them into high level and low level.
• Utilized corporation developed Agile SDLC methodology used scrum work pro and Microsoft office software to perform required job functions.
• Wrote various SQL queries to create, update, modify tables, create reports, and retrieve information from the database. Derive the required data by SQLs and export into Excel files
• Developed user guides, provides user training, and supports the user in development of work processes.
• Supported UAT to evaluate the system performance and developed system plan to quality center, review design, view test cases.
• Generated reports for quality metrics using SQL Queries.
• Maintained Change and Traceability Matrix throughout the project keeping track of the scope, timelines and budget of the project as well as collaborated with development team to determine the security access and it is tracking to ensure privacy of End users.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: SQL Server, Windows XP, Informatica, Facets, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, Java, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML.