SUMMARY

• 7+ Years of professional experience as a Business Systems Analyst /EDI Analyst a subject matter of expertise in Healthcare Domain.
• Experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, System Change Document, Functional Specifications, experienced in writing Use Cases.
• Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be'/'Go-To' processes.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Experience in SQL Server 2005 concepts SSIS (SQL Server Integration Services), SSAS (Analysis Services) and SSRS (Reporting Services)
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare
• Good working knowledge of Claims processing, Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction Set EDI X12 837, 270/271, 276/277, 278, 834, 835.
• Experience in developing and imparting pre and post implementation training, conducting GAP Analysis, User Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis.
• Expert in Tracking and Managing the Requirements using Requirement Traceability Matrix (RTM) that controls numerous artifacts produced by the teams across the deliverables for a project.
• Proficient experience in working on FACETS environment and possess an extensive knowledge about various modules of FACETS system such as claims and membership.
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams.
• Worked extensively on the EDI Transactions via EDI 270, EDI 271, EDI 276, EDI 835, EDI 837, EDI 277, 999.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Extensive knowledge and understanding of MMIS, Electronic Medical Health Record (EMHR) and Pharmacy Benefit Management (PBM).
• Analyzed test results to ensure existing functionality and recommend corrective action where necessary.

TECHNICAL SKILLS

Business Modeling Tools: Rational Enterprise Suite, Requisite Pro, Rational Rose, Clear Case, Visio, UML, Share Point, Microsoft Office.

SDLC Methodologies: Agile, Waterfall, Jira, Spiral, Spiral, Rup Process and Prototyping

Operating Systems: MS Windows, Unix/ Linux

Project Management/Business Applications: MS Project, MS Visio, MS Word, MS Excel, MS Access, MS PowerPoint.

Databases: SQL Server, MS Access, MySql, Oracle SQL.

PROFESSIONAL EXPERIENCE

Confidential, East Brunswick, NJ

Sr. Business Analyst

Responsibilities:

• Collected data for configuration and display.
• Assisted in Functional, Integrated, Mock Activation, and User Acceptance testing, as needed.
• Acted as a liaison between the IT department and other staff both during the implementation and after the activation, as required including rotation of on-call support duties.
• Worked on a project associated with Medicaid and Medicare.
• Documented the test plans and developed related documents.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS Visio.
• Maintained documents and the effect of proposed changes on the project schedule and costs.
• Wrote UAT Test Plan, organized and conducted User Acceptance Testing with clients and worked as a part of support team.
• Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts. Created Use-Cases and Requirements documents to document business needs.
• Conducted JAD sessions for requirement gathering, review, and approval.
• Coordinated with Development and Business team to develop high level Business and Technical documents.
• Assisted in writing and revision SOPs in DCM and trackwise as per current USP.
• Managed all revisions in the specifications and standard procedures.
• Managed all SOP trainings on LMS.
• Conducted investigation on trackwise regarding all out of specification results and deviations.
• Assisted/Performed general GMP audits.
• Proposed CAPAs to resolve quality matters.
• Reviewed batch records and quality control data for first to file products. Quality control testing for Raw materials
• Issuing certificate of analysis on active and inactive.
• Calibrating balances, pH meters, Malvern, HPLC, UV, melting point and atomic absorption.

Confidential

EDI Analyst/ Business Systems Analyst

Responsibilities:

• Analyze, design and implementation of multiple work initiatives to provide technical solutions, such as imports, reporting and queues processes for multiple markets.
• Involved in Validation of HIPAA/EDI for 270/271, 276/277, 837, 837i and 835 claims used for professional, Institutional and Dental billings by Writing Test cases, Test Plans
• Lead cross functional AGILE teams to achieve goals and high level of performance.
• Used JIRA as an AGILE tool to manage defects and tasks.
• Involved in Data mapping, navigating data structures, process mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Raise service request with Oracle technical support and coordinate in speedy resolution of high prioritize issues.
• Discussed all documents with Subject Matter Experts (SMEs) on SharePoint in requirement sessions, Joint Application Development JAD sessions (for brainstorming), root cause analysis and approval sessions were done. Involved in HIPAA assessment and HIPAA X12 EDI transaction mapping for X12 267 with long-term disability (LTD) and short-term disability (STD).
• Worked on the EDI 834 inbound and 834 outbound data movement with our trading partners.
• Extensively worked on claims processing and with HIPAA in different EDI healthcare transactions 837, 835,834, 820, 270, 271, 276, 277 and 278, file transfer success/failure.
• Extensively worked on EDI 834 on FACETS to customize and configure membership benefit enrollment data files according to the need of the proposed system.
• Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS and EDI
• Analyzed EDI transactions in XML and X12 responses. Involved in analysis of HIPAA compliance and EDI Transactions sets and took part in discussions for designing the EDI transactions
• Architecture and design work for specific EDI Mapping Projects, Mapping and implementing message translations for connecting trading partners to each other and to the applications
• Developed and maintained EDI transactions Implementation Guidelines for the ANSI X12 transactions documents.
• Standardized functional requirements, specifications, technical design specs & data processes for Webservices/API project.
• Extensive experience in development of T-SQL, OLAP, PL/SQL, Stored Procedures, Triggers, Functions, Packages, performance tuning and optimization for business logic implementation.
• Validated Web Services as part of API implementation by testing Request and Response XML files.
• Integrated third party services for enhanced due diligence on on-boarding customers, companies and ID documentations using REST API.
• Prepared implementation plan and negotiated agreement on EDI file specifications with Trading Partners and vendors in accordance with HIPAA guidelines.
• Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in Validation of HIPAA/EDI for 270/271, 276/277, 837, 837i and 835 claims used for professional, Institutional and Dental billings by Writing Test cases, Test Plans
• Worked on EDI Health Care Claim Payment/Advice Transaction Set (835)
• Tested Schemas of EDI ANSI X12 Claims (837-HealthCare Claim and 267-Individual life, Annuity and Disability Application) and Eligibility forms in XML.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.

Confidential, Baton Rouge, LA

Business System Analyst/ EDI Analyst

Responsibilities:

• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers
• Documented complex Business requirements and made process flow diagram for the 837, 270/271, 276/277. & 835Remittance transactions of Medicaid claim processing system enhancement by using tool Blueprint.
• Extensively worked with FACETS Implementation, FACETS Billing, Claim Processing and Subscriber/Member module.
• Gathered and documented functional requirements for testing and verification of HIPAA.
• Web Portal Development - Worked as a Business Analyst gathering requirements to develop a referral portal and delivered business artifacts like BRD, FRD, and UML using tools like Blueprint & VISIO.
• Expert in preparing code to Interface with Teradata, SQL database with UNIX and Windows operating systems
• Involved in Data mapping, navigating data structures, process mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Raise service request with Oracle technical support and coordinate in speedy resolution of high prioritize issues.
• Planning project activities viz. Scoping, Estimation, Tracking, Change Management, Delivery Management & Post Implementation support. Work closely with core departments to ensure accuracy, service delivery and effortless process flow
• Created process flow diagrams describing provider and member access to the web portals.
• Worked with cross-functional teams to support JIRA in ways that will help them improve their business process.
• Coordinated with team leads to determine needs and how best to implement JIRA within department.
• Created and configured new JIRA projects and worked with departments to maintain existing JIRA projects.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and the performance of the application from various dimensions.
• Prepare required regulatory reports which show the progress on the collection reporting and analysis on HEDIS. Involved in 835/837(P/I/D)/834 (ANSI X12) transaction with implementation guides.
• Worked effectively with Clinical Performance Managers to develop and present insightful and actionable analysis.
• Mapped the clinical editing tool related data elements to the internal XML elements.
• Documented the UAT (User Acceptance Testing) Plan for the project and worked with the UAT Team to ensure every acceptance criterion for the requirements has been included in the UAT task plan.
• Maintained the Traceability Matrix Table to uniquely trace the identified business requirements to general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked.
• Worked extensively with the QA team for designing Test Plan and Test Cases for the User Acceptance Testing.

Confidential

Business Systems Analyst

Responsibilities:

• Analyze complex business problems and assess feasibility of the proposed enhancements and systems automations.
• Act as liaison between business users and IT development team and work closely with Subject Matter Experts (SMEs) to help create Project Requirement Documents (PRDs), Functional Specification Document (FSD) and use cases.
• Gathered requirements from users and stakeholders using different elicitation technique such as JAD session, work session, interviews, brainstorming and document analysis.
• Provided leadership and direction to lesser experienced Business Analysts.
• Designed, Implemented HIPAA EDI transactions in X12 responses and of 837, 835, 277 and 999 and conducted QA and validation defect testing.
• Extensive analysis on 837P and 837I Electronic Data Interchange EDI file to analyze claim lines, amount paid, and other secured information on professional claims and Institutional claims.
• Creates and updates complex reports from multiple systems both on a regular schedule and as needed basis, using Excel, Access, SQL, etc
• Used TriZetto a HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc)
• Designed High-level design, for new process, integrating with legacy and Facets.
• Successfully worked with Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on important dimensions of care and service.
• Involved in configuration of Facets Claims, Subscriber/Member Application group.
• Analyzes and interprets encounter data to identify potential issues and trends; Ensure compliance with regulatory bodies
• Analyzed the EDI X12 data elements in the existing system to validate it against the data elements required in new system
• Decompose business and user requirements into system and software functional requirements.
• Define system quality and operational attributes, external interfaces, constraints, rules, and other non-functional requirements.

Confidential, Columbus, OH

Business Analyst

Responsibilities:

• Developed project scope statements, business requirements documents and functional specifications for all the projects.
• Conducted walkthrough of BRD in the JAD Sessions with users and developers. Collected specific information to include in the Functional Requirements Document (FRD).
• Conducted user interviews, gathered requirements, analyzed the requirements by using Rational Rose, Visio and Requisite pro.
• Performed the GAP Analysis and Impact Analysis for all business requirements having an impact on the existing application.
• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Developed test plans to validate required functionality. Test plans were written with both positive and negative data to verify that only valid data was moved according to business rules.
• Studded the issues of failing in the production or not working properly, explored the root cause and fix issues.
• Updated the functional design document for NPI related changes in the Encounters project.
• Worked on multiple 837 and multiple Eligibility (270/271) and healthcare claim status (276/277).
• Involved on HIPAA translation based claim processing systems (claims and encounters) and other ANSI X12 EDI implementations.
• Worked on Claims, Customer services, Members, Billing-Enrolment interfaces and extensions for FACETS as a part of FACETS implementation team.
• Troubleshoot any problems found within FACETS and when testing the SQL data database while validating the business rule.
• Worked in testing the Professional, Institutional Claims processing and adjudication and validate data with FACETS.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Analyzed data and created reports using SQL queries for all issued Action Items.
• Contacted with Client to accommodate any new change in requirements as well to discuss the project status.
• Coordinated between the project group and the operations group. Helped design scope document and the request for proposal after extensive analysis and coordinated with top management for the approval process.