- Senior Business Analyst with experience in various Healthcare areas like Enrollment, Benefits, Claims, Medicare and implementation of HIPAA.
- Experience working in all phases of SDLC from analysis, design, development and testing along with in depth understanding of the Waterfall, Agile and Rational unified process methodologies.
- Worked as SME for project funding, milestones, financial and system analysis, support of MMIS.
- Created Epic and User Stories, groomed those stories and maintained the backlog.
- Used JIRA to write, gather and document Integration and technical requirements from SMEs.
- Experienced in working with product backlogs, sprint backlogs along with creating user stories and prioritizing user stories and keeping track of burn down charts.
- Efficient in Gathering, Documenting and validating the requirements in a format that is useful (BABOK Guide) to the business area experts and the technical team. Experience in working with PMO tools, templates, best practices and processes (PMBOK). Proven track record in ensuring extensive data quality and project control throughout projects' lifecycle with expertise in Risk, Impact and Issue Analysis and Management.
- Strong writing skills in preparing Business Requirement Documents (BRD), System Requirement Specifications (SRS), Software Requirement Specifications (SRS), Use Case Specifications, Functional Specifications (FSD), Requirement Traceability Matrix (RTM) and Technical Design Document (TDD).
- Excellent knowledge of HIPAA standards, Electronic data interchange EDI Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, hospital coding, reimbursement methodologies, CPT codes, ICD - 9, ICD-10 coding and HL7.
- Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing.
- Knowledge of EMR/EHR, HMO/PPO/POS, Health Care Reform and Patient Protection and Affordable Care Act PPACA, Medicare Part A, B, C, D, Medicaid, Medicaid Management Information Systems MMIS, Medicaid Information Technology Architecture MITA, and Health Care Reform.
- Wide knowledge of Independent Verification and Validation IV V projects MMIS and Data Warehouse.
- Knowledge of Explanation of Benefits EOB for a member or Explanation of Payments EOP for a provider.
- Basic understanding of Healthcare Jargons such as Health Insurance Exchange HIX
- Knowledge of various areas like CPT, HCPCS, General equivalence Mappings GEM, ICD9/ICD10 Conversion, Healthcare claims processing, Medical policies, Benefits, Network Provider Management, Enrollment/Membership and Utilization Management etc.
- Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
- Performed planning and development of Test Plans, Test Strategies, Test Scripts and executing tests to meet product’s business requirement.
- Strong experience with Care Management and Care Transition Programs designed to target high cost, complex patients for improved care transitions and care coordination using the embedded nurse care manager and medical home model
- Extensive experience of working with Care Management teams responsible for coordinating primary and specialty care, applying for government assistance benefits and Enrolling in medical day programs
- Excellent experience with Care Management workflows such as Complex Case Management, Monitored Case Management and Lifestyle Management
- Proficient in bug tracking/test management tools like Quality Center, Clear Quest, JIRA and Confluence.
- Experience in Preparation and Execution of appropriate business test scenarios based on Functional & Technical Requirements.
- Experience in providing UAT and postproduction support for web-service applications.
- Facilitated Change Management across entire process from Project conceptualization to Testing through Project Delivery, Software Development and Implementation Management in diverse Business and Technical Environments.
- Personal skills include Excellent Communication, strong sense of Organization, Effective Time Management and have the ability to work in a team as well as independently.
SDLC Methodologies: Agile, RUP, Waterfall
Platforms: Windows, Unix, Linux, Mainframe
Languages: SQL, Java, HTML, XML and UML
Databases & Tools: SQL, Access, MYSQL, Oracle
Quality Management: HP ALM/Quality Center, Rational Test Manager, Rally, JIRA, SOAP UI
Business Modeling Tools: Rational Rose, Microsoft Visio, MS Excel, MS PowerPoint
Change Management Tools: Rational Clear Quest, Requisite Pro
Project Management: Microsoft Project Professional
Others: MS (Visio, Outlook, Access, Word, Excel, PowerPoint) SharePoint
Senior Business Analyst
- Subject matter in this training project include member related eligibility determination, enrollment and disenrollment, eligibility inquiry, capitation premium payment, health insurance premium payment, Medicare premium payment, premium invoice, program policy, and state plan. I will be constantly involved and be familiar with the Affordable Care Act and impacts on Medicaid eligibility and member related processes.
- Participated in Sprint Planning, Daily Scrum Stand Up, and Sprint Retrospective meetings.
- Participated in the development and grooming of Project Backlog Stories (Requirements) with business and technology partners.
- Lead the conversion of the legacy Flexi financial accounting system to the new Financial Accounting System.
- Provide Agile coaching to peer business analysts for Agile Scrum and Kanban best practices and Rally Software instruction.
- Understood and deciphered the Business Logic behind the “Document Number Generation” for KDP and BCCDT program documents. Deciphered High Level Business Logic as well as COBOL job packages/program codes to understand and discuss with its SME on CMS-21; CMS-64; CMS-37; CMS-416 and CMS-372 Federal mandate reports.
- Describes ongoing changes in states’ federal medical assistance percentages (FMAPs)—the share of the basic Medicaid program provided by the federal government.
- Provided subject matter expertise for the implementation of Health Exchange Business Process with a special focus on Medicaid Integrated Eligibility, Plan Management, SHOP/SHOPPING, and Financial Management Business domains.
- Was responsible for Production set ups for multiple operating units for Purchasing and GL, AP, AR and Cash Management.
- Facilitated Scrum ceremonies, workshops on SCRUM and decomposed Epics into User Stories using Vertical Slicing technique.
- Implemented Scrum with JIRA to track the progress of project and involved in creating Product Backlogs, EPICs and User Stories.
- Created UML notations for Object Oriented Design and Documentation for Care Management workflows.
- Identified opportunities for business process improvement through meetings with business users and developers resulting in major improvements in product and processes.
- Extensively involved in validating the financial reports and running the SSIS packages for the financial cycle process.
- Provide lead oversight and analysis on the T-MSIS project for Confidential Inc. by CMS 21/64.
- Involved in validating the remittance advice reports.
- Shared Costs of health benefits between the federal government and state depending on a state’s FMAP.
- Responsible for the ongoing development and maintenance of all procedures relating to AP/AR department.
- Collaborated/Communicated with all stakeholders, business units & executive management on go- to-market/ product launch strategy.
- Worked with production support team to ensure the product was up and running in prod environment.
- Responsible for UAT test management activities.
- Assisted with source to target mapping of MITS data to the T-MSIS data as required and documented in the T-MSIS Data Dictionary developed by CMS 21/64.
- Owned and prioritized new scope and features and updated existing roadmaps in an agile methodology. Created functional level user stories and user flows.
- Work with other BA to create an environment to foster knowledge transfer related to agile practice and product features and functionality.
- Developed Scope of the project, Business requirements, Functional requirements and created user stories for the project.
- Lead calls daily and communicated with IT management and developers to follow through on progression of various initiatives and assigned development tasks.
- Lead portfolio/project estimation and presentation activity to Gate governance reviews for approval and fund allocation.
- Lead and Conducted JAD session with the SME's and project team members.
- Worked as an SME on Encounters Data for capitated payments system and ensuring correct encounter data being provided to State Medicaid agency.
- Gathered the chronic care management requirements through reference options like CMS, business owners, physicians.
- Documented the care management workflow including time management and coordination of care by various care team members.
- Managed the team of consultants responsible for developing on-demand Medicaid Management System MMIS reports.
- Worked as SME on various subject matter areas including state reporting for Medicaid encounters data & claims data.
- Responsible for validating claim processing transaction of MMIS.
- Involved in Jira testing and tracking the bugs along with communicating with the vendor team to get them modified & resolved
- Created a spreadsheet with these Providers along with their Provider ID, National Provider ID (NPI), Contact name, Technical Support name and sent the document to Provider Enrollment team to work.
- Analyzed transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment), 276-277 (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
- Involved in Recipient, Claims entry, Claims adjudication, Prior approval authorization, and TPL subsystems.
- Involved in requirements gathered by interacting with MMIS business analyst and translating those business needs into a systems design specification.
- Conducted end-to-end source to target validation of a sample of claims, encounters, pharmacy, eligibility, and provider by year.
- Used Jira Agile management tool to maintain team metrics and make visible to team (including burn down charts) and Work as a Jira admin assign new user to project, delete user and Create Project.
- Reviewed System and Integration Testing SIT, Regression Test Cases by using ALM for the Core MMIS's functional areas e.g. Provider, Member, Web Portal, Finance, and Reference.
- Validated the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
- Verified encounter denials, MCO denials and MMIS denials including reason codes and description of reason codes.
- Created Test plans and test cases.
- Created architecture Solution flows, UML diagrams, service charters and detailed message specifications for development of messages/interfaces which using Business Process Modeling Notations (BPMN).
- Extensively used SQL queries using query Analyzer for data analytics, data mapping, verification and validation.
- Developed test scenarios and implemented test plans for Product test, integration test, system test and user acceptance test (UAT).
- Reported Bugs using ALM/Quality Center.
- Provided extensive support to Business Solutions Quality Assurance Department.
Environment: SQL Server Management studio, QNXT, Flexi Financials, Rational Manual Tester, Clear Quest, Work flow Application, Text pad, Microsoft Excel, ASG Cypress, SSRS Application, Quality Center 10.0.
Business System Analyst
- Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
- Coach team members on Agile principles and Scrum methodology.
- Gathered/reported all relevant Agile metrics (burn down charts, Team velocity, cycle time, cumulative flow, etc.).
- Ensured the development teams are practicing the core agile principles of collaboration, prioritization, team accountability, and visibility.
- Worked in an Agile/Scrum environment. Wrote user stories that served as business requirements and submitted enhancement and bug resolution requests to the technical team. Reviewed and signed off on Use Cases and Report Specifications.
- Created the list of backlog items and prioritized the product backlog in Jira during the sprint planning meetings.
- Understood the requirements of care management and its relevance with chronic care management laid out by CMS.
- Study of exiting business process of GL accounting, AR and AP
- Analyzed on identifying the patient population requiring care management through different care team members (both within physician office and outside physician offices).
- Led cross functional meetings to review and prioritize the Product Requirements and associated timelines.
- Facilitated Daily scrum meeting, conducted sprint retrospective, sprint planning and sprint review meeting and followed up on action items for continuous improvement
- Maintain Master AP/AR filing systems.
- Contributed to the project's overall understanding of Medicaid Management Information System Core MMIS.
- Served as a lead for requirements team and subject matter expertise (SME) with healthcare systems.
- SME (Subject Matter Expert) in Encounter Claims processing & management, mentored & trained entry levels.
- Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
- Gathered the requirements from the Business Owner SME.
- Assessment of the current MMIS and EDI claims, documentation of business and technical requirements, preparation of cost analysis and implementation of new MMIS automation system.
- Facilitated JAD sessions for Requirement Validation and requirement gathering for the new MMIS.
- Involved in HIPAA EDI transactions such as 270, 271,837 (P, D, I), 276, 277, 834, 820, 278,999/TA1, and 277 CA.
- Identified opportunities for the creation of algorithms and data models to detect incorrect or fraudulent Medicaid billings.
- Created new security reports and maintained other security reports within MMIS system.
- Verified claim, encounter and pharmacy original, voids and replacements logic.
- Worked on IBM mainframe environment for Medicaid Management Information System impact assessment.
- Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, Sequence Diagram, Collaboration Diagram that include Functional and Non-Functional specifications to hand off to development teams.
- Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting
- Defects and bug testing by using Quality Center, Configuration management and Version control with JIRA.
- Created Test cases, Test scripts for the different modules of the system using HP ALM.
- Developed Test Script for Functionality, Security, and Regression testing.
- Worked closely with the Quality Assurance team and developed test cases, test scripts using the developed use cases as the platform, and conducted User Acceptance Testing (UAT).
- Developed SQLs for Extracting data from database and built data structures, reports.
- Performed in depth analysis of data & prepared periodic reports using MS Excel and SQL.
- Worked closely with QA and Developers to clarify/understand functionality, resolve the issue, and provided feedback to nail down bugs.
Business System Analyst
- Conducted daily Scrum meetings during the Sprint Development as a part of Agile Methodology.
- Gathered requirements from user stories, BR and SR documents in a fast paced Agile Environment and in a test driven development.
- Worked with the scrum team to facilitate high level planning to establish the project baseline and sprint.
- Created backlog of User Stories and categorized them into different sprints based on their priority in JIRA.
- Created dashboards/views in JIRA & SharePoint for effective tracking and to ensure teams deliver on time and continuously monitor risks and review with managers on weekly basis.
- Identified Use Cases from the requirements. Created UML Diagrams including Use Cases, Activity/State Charts, Sequence and diagrams, Data Flow Diagrams and ER Diagrams using Rational Rose and MS-Visio thus defining the Business Process Model and Data Process Model.
- Conducted JAD session with different stakeholders while developing user interface and web services.
- Created 837(P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837(P, I, D), 834, 835, 270, and 271.
- Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
- Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare and Florida Medicaid.
- Utilized SQL server to run basic queries and obtain necessary data for Medicaid and Medicare Encounters.
- Using SQL query to produce data for 270 EDI X12 file and create 270 files and submit to MEVSNET to check dual snip member for Medicaid benefits eligibility.
- Reviewed vendor files for any errors, missing segments, and for missing data on X12 file. Ensured file has complete data before encounter can be submitted to Medicare and Florida Medicaid.
- Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 & 271HIPAA EDI Transactions using MS Word, MS Excel.
- Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifecs.
- Utilized Ramp Manager Application from Florida Medicaid to check X12 files for any error before submitting to Florida Medicaid.
- Developed and updated Requirements Traceability Matrix (RTM) using Rational Rose, mapped the developed Test Cases to the requirements to ensure that the requirements were fully tested and implemented according to the specifications.
- Created Ad-hoc reports when the business needed using SQL for collecting the data.
- Worked extensively with QA Team in understanding and documenting Test Cases, System Test Plans (STP).
- Performed User Acceptance testing & End to End testing in interaction with Offshore QA/dev teams for various system releases & pushed them to production.
- Created UAT Test Plan to assist UAT testers during UAT. Participated actively in UAT and worked as SME along with testing during UAT.
- Prepared Test Cases /Test Data according to Business requirements and assisted QA team in testing.
- Developed project schedules, conducted project status meetings and managed resources during all phases of the SDLC.
- Extensive backend testing using SQL queries, generated the reports to ensure the data integrity and validated the business rules.
- Interacted with Developers and Users in resolving risk factors and other issues.
Confidential, Dayton, OH
Business Systems Analyst
- Participated in Business Requirements with vendors, business owner and SMEs to gather business requirements.
- Facilitated collection and prioritization of functional requirements from system users. Documented the Business Requirement Documents (BRDs), Functional Requirements, and non-functional requirements.
- Worked in Software development life cycle (SDLC) using Agile Scrum methodology.
- Involved in daily scrum/standup meetings to produce artifacts- product backlog, sprint backlog along with documenting the meeting minutes and send them out to the participants for confirmation.
- Facilitate JAD sessions with product management, SME’s, and customer operations to gather business enhancement requests.
- Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
- Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
- Worked on EDI transactions: 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
- Worked on EDI 837 for checking that if receiving claims has all the required information or not.
- Testing 837 claims coming to us from providers.
- Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
- Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
- Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins.
- Created user stories for business requirement and technical responses and upload them in JIRA of each project.
- Worked with the Quality Management team to ensure that requirements documentation can be easily translated into test plans and ensure that the proper testing plans have been completed.
- Used Quality Center to plan tests, manages test assets, create and run manual and external scripts to check GUI and functional features of the AUT.
- Wrote numerous test cases based on test strategies.
- Involved in Functional System Testing, Integration Testing, Regression Testing, and User Acceptance Test using the test cases before releasing the application.
- Tracked down the issues and subsequent decisions and maintaining the SharePoint.
- Wrote SQL Queries in MS Access to sort data and analyses the large set of data during project life cycle.