SUMMARY

• More than 12 years of Business Analyst / System Analyst experience with exposure of Healthcare, IT business Analyst and Retail domain. Direct PBM benefits experience across both Commercial and Medicare Part D health plans.
• Experience in SDLC, Agile, Waterfall and SCRUM software development methodologies.
• Proficient at coordinating with stakeholders, vendors, Subject Matter Experts (SMEs), Project Manager (PM) and end users and elicitation of requirements through Joint Application Design (JAD) sessions, Brain storming sessions, interviews, Surveys and questionnaires, prototyping, benchmarking, Requirements workshops, focus groups, document analysis, Joint Application Requirement (JAR) sessions and Rapid Application Development (RAD).
• Skilled in gathering and converting User Requirements into Business Requirements (BRD), Functional Requirement Documents (FRD), Functional Requirement Specifications (FRS) System Requirement Specification (SRS),and visualizing graphical user interface (GUI) using mockup screens.
• Expertise in Gap Analysis, SWOT analysis, risk analysis, cost - benefit analysis, feasibility analysis, and impact analysis, ad-hoc reporting.
• Experienced in creating workflow analysis and design, Unified Modeling Language (UML) diagrams like activity diagrams, sequence diagrams and use case diagrams through MS Visio, What-IF scenario analysis (WISA), To- Be Scenario Analysis, Gap Analysis, User Interface (UI) design, User Experience design (UX), prototypes and wireframes, Managing Requirement Traceability Matrix (RTM)
• Strong knowledge of creating conceptual data models, ER diagrams, data mapping, data profiling, data verification, data integrity, ETL process, data normalization, data dictionary, SQL queries for data analysis and data validation, ad-hoc reporting.
• Experience with health care systems: QNXT, FACETS, Medicare Part A, B, C, D, Medicaid systems, and validating General Equivalency Mappings (GEMs), Technical Report Type 3 (TR3) Implementation Guide, and Companion Guide.
• Experience in configuration of claims processing applications, front end Claim edit, claim adjudication process, claims management process, real time claims adjudication, Electronic Medical Records / Electronic Health Records (EMR/EHR) and Medicaid Management Information System (MMIS),and Medicaid Information Technology System (MITS).
• Experience working with managed care plans, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans, Coordination of Benefits (COB), Explanation of Benefits (EOB).
• Have knowledge HIPAA(Health Insurance Portability and Accountability Act) transaction and code standards and electronic data interchange (EDI) standards like X12 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrollment) and knowledge of claims encounters process, Fiscal Intermediary Standard System (FISS) Medicare Part A claims process.
• Experience in Release planning, Acceptance criteria, definition of done, definition of ready, Potentially Shippable Product Increment (PSPI), minimum viable product (MVP), and good understanding of test-driven development.
• Proficient in creating and managing Use Cases, User Stories, Test cases, Test plans, Test reports, Test scripts.
• Expertise in RPA processes, including requirements gathering, solution designing, coding, testing, debugging, documentation and implementation using different tools such as UI-Path.
• Skilled at performing User Acceptance Testing (UAT), handling Change Request, and Configuration management.
• Used tools like JIRA and RALLY to create and maintain Product Burn-down chart, Sprint Burn-down/ Burn-up chart.

TECHNICAL SKILLS

SDLC Methodologies: Waterfall, Agile (SCRUM, XP), Hybrid (SCRUM-Waterfall)

Operating Systems (OS): Windows XP/8/10/Vista, Linux, Mac OS

Modeling Tools: MS Visio, Mock-up screen

RPA Tool: UI-Path

Requirement Management Tools: JIRA, Rally, Jira Government Business Division, ServiceNow for the tickets creation, Confluence, Trello ( Task Management application),SharePoint for document management, Salesforce

Testing Tools: HP QC, HP ALM

Languages: SQL, HTML, CSS, XML

Reporting Tools: Tableau Desktop (in process), IBM Cognos

Architecture: Service Oriented Architecture (SOA), 3 Tier Architecture, N-tier Architecture, Cloud Platform (SaaS)

ETL Tools: Informatica (Power Center), SQL Server Data Tools, Cognos Data manager

Databases: MySQL, IBM DB2, Oracle

PROFESSIONAL EXPERIENCE

Sr. Business Analyst/BSA

Confidential

Responsibilities:

• Requirements Gathering and Analysis Worked closely with the Senior developer, Manager and Technical Lead for understanding the functional and technical requirements and design.
• Automation test frameworks and by users to ensure that user intent is effectively captured and tested
• Involved in identifying opportunities to automate manual tasks using Robotics Process Automation RPA technology.
• Processed and supported requests and bug fixes to meet program deliverables to ensure RPA implementation success.
• Preparation of RPA Use case documents, Business Process Design Documents (BPR) & Process Design Documents (PDD), Engage with RPA team on automation process.
• Develop business cases/stories for prioritization
• Develops and analyzes business performance reports (e. g. for claims data, provider data utilization data) and provides notations of performance deviations and anomalies.
• Translate requirements into technical and non-technical document
• Ability to understand document data flow, systems and interdepartmental processes
• Supports documentation within the software development lifecycle
• Coordinate and collaboration with Offshore and onshore team, Developers and Product Owner
• Created Client Intent Matrix in Maintenance of Business phase.
• Maintained Projects materials, updated Review Checklist and Functional Design document for Plans on the SharePoint site.
• Sought Root Cause Analysis and developed appropriate corrective action related to Med D.
• Performed defect analysis in Pre-Prod by Manual Claims Adjudication.
• Participated in Defect Triage, Client, and BRM calls, Maintained Defect/ Issues/ Observations Tracking sheet.
• Ensured RPA deliverables are completed per the project plan.

Confidential

Sr. Business System Analyst

Responsibilities:

• Ensured compliances with all Governments Business Division applicable standards, policies and procedures to establish rapport and credibility while creating Business Requirement Documents (BRD).
• Conducted through research on state mandated claim edits before inserting them into the claim controller engine for accurate adjudication process.
• Ensured business rules edits are properly examined and verified before creating the business requirement documents for the development.
• Conducted interviews with the end users, subject matter experts, stakeholders to determine how to deliver optimal benefits for their business requirements.
• Coordinated with the number of departments to document effective solutions that helped reduce the return of the error prone claims with missing edits.
• Directly involved in saving high dollar value claims by coming up with the list of edits that needed immediate implementation.
• Provided appropriate guidance to developers ensuring the business requirements will be implemented into the system and how its assignment would have delivered appropriate business edits rules to stop claims before adjudication.
• Facilitated and documented test case scenarios to validate the acceptance criteria for the proposed business need edits.
• Participated backlogs grooming, sprint planning, daily scrum meetings by following iterative method of managing project in a highly collaborative manner.
• Work diligently on products backlogs refinement-adjust, split and determine dependency of business requirement edits.
• Removed impediments to improve the capabilities of the team members and ensured sprint iteration takes place within the set timeframe.
• Demonstrated finalized products functionality during the Sprint Review Meeting with the Product Owner and Stakeholders.
• Handle all aspects of a project life cycle with Agile framework- executed deliverables such as process mapping, data flow diagraming, requirements specification and acceptance testing.
• Continuously communicated with the project owner to ensure expectations are kept in line with projects status.

Confidential

Sr. Business System Analyst

Responsibilities:

• Involved in updating and/or reworking previous documentation on their Membership Enrollment System for Florida to get them in sync and up to date with their current new system in place.
• Involved in System Integration, Compliance and User Acceptance Testing and Validation of Medicaid claims processing and Electronic Data Interchange (EDI) translation in compliance with the 5010A Health Insurance Portability and Accountability Act (HIPAA) transactions 837 I/P.
• Analyzed the gathered requirement and reviewed Business Requirement Document (BRD) /Functional Specification Document (FSD)
• Reviewed and streamlined existing CRM processes, information, and data requirements to ensure accurate adoption metrics reporting. Deactivated users to release licenses. Analyzed if the system abides HIPAA regulations as portal displays member's private information. Performed data analysis and ran various SQL queries to critically evaluated test results.
• Gained understanding of Medicaid policy and billing requirements and documented needed changes to policies and billing manuals related to ICD10 through facilitation with internal KMHP program areas.
• Configured and maintained of Facets and other application software products, such as Claim check, Facets.
• Creating artifacts such as URS, FRS, Traceability Matrix, project plan, BRD, test plans, and test cases.
• Involved in Processing QNXT 837 Healthcare Claims (Institutional &Professional) in PORTAL.
• Documented business needs for ICD10 resulting from the HIPAA 5010 gap analysis.
• Used requirement elicitation techniques such as JAD Sessions and Document Analysis to gather information regarding the application from the KMHP SME and EDS along with the State of Florida people.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA 5010 code sets, ICD-9, ICD 10 coding and HL7.
• Experienced with the HL7 data transactions.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Performed activities to comply with annual HEDIS data collection and analysis, preparing recommendations to increase rates as appropriate.
• Conducted meetings with the project managers to review the project plans.
• Recommend best practices for project plans to the project managers for their successful implementation.
• Involved in testing QNXT Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.
• Carried out UAT by developing test plans, test scenarios, test cases, and test data to be used in testing based on business and user requirements, technical specifications of the product.
• Maintained open and clear communication with the team on change requests.
• Determined the requisite training for both internal staff and Medicaid provider groups and assisted in the development of training materials.
• Maintained project documentation in a central repository and created a weekly report on the updated project plans and maintained them.

Confidential, Indianapolis, IN

Business Analyst

Responsibilities:

• Created business requirements document, functional specifications document and design documents
• Identified the scenario based on business requirement and HIPAA compliance for each transaction such as 837 and 276/277
• Documented and gathered functional specification for 837(claims), 278(Authorizations), 276/277(Claim status/response), 834(enrollment) and 835(claim adjustment).
• Analyzed and Processed Medicare claims using the EDI transactions 270/271, 278
• Involved in claim adjudication process of Facets application
• Used XML and other type of formats to transport, store, and structure and represent data and derived information from source to destination data maps.

Confidential

Business Systems Analyst

Responsibilities:

• Worked as a liaison between the business client and development team for the implementation of 4010 to 5010 transition in compliance with HIPAA standards.
• Involved in the HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 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 document approval and submission system on COTS application for pharmaceutical regulatory submission system
• Identified the business functions and processes, and prepared system scope and objectives based on user needs and industry regulations.
• Defined terms, conducted stakeholder analysis, elicited business needs, conducted business process modeling, and facilitated JAD sessions. Elicited, documented requirements and use cases. Analyzed, validated & prioritized requirements; traced requirements to related project documentation (process models, designs, test scenarios & scripts).
• Documented the Requirements and circulated them to Business & Technical teams for Signoffs.
• Coordinated with the developer and testers for transition of EDI X12 4010 series to 5010 series. Maintained traceability through updates to the Requirement Traceability Matrix (RTM) using Requisite Pro.
• Identified testing scenarios and defined Test Cases for detailed functional testing.
• Developed a Schedule and identified project milestones.
• Analyzed business scenarios to track possible business outcomes for the functions which could be incorporated into more detailed test scripts.
• Reported project progress to the team, senior management and all stakeholders periodically.
• Identified risk and project impact and performed risk assessment and mitigation.