SUMMARY

• 6+ years of comprehensive knowledge of Business System Analysis methodologies, Software Development Life Cycle (SDLC) using Rational Unified Process (RUP), Waterfall and Agile (Scrum).
• Ability to gather and document Business Requirements, 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' processes
• Expert in insurance-payor systems - Claims, Billing with backend data mapping, data integration.
• Knowledge of different modules within Healthcare Claims Adjudication Process (Membership process, billing process and enrollment & Claims process).
• Hands-on experience across a range of logistics functions including: production planning, inventory management, customer service, forecasting, transportation and distribution with a diverse group of companies, products, and services.
• Well acquainted with team on JIRA tool for Agile/ Scrum Methodologies.
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Strong experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, and Insurance Claims.
• Experiences in end to end testing of Facets Billing, Claim Processing and Subscriber/Member module
• Experience in writing Business Requirements Documents (BRD) and Functional Requirements Documents (FRD). Experience in Gap Analysis.
• Experience in matching requirements with Requirement Traceability Matrix.
• Experience in conducting Requirement Gathering sessions, Feasibility Studies and organizing the software requirements in a structured way.
• Good understanding of insurance policies like HMO and PPO and proven experience with HIPAA EDI transaction codes such as 834 (Enrollment & Maintenance).
• Responsible for EDI strategies (EDI 835, 837, … 278) enabling Health Care Providers and Insurance Careers to communicate effectively.
• Interviewed Subject Matter Experts (SME), Stakeholders and business leaders with detailed questions and carefully recording the requirements in a format that can be reviewed and understood by business and technical stakeholders.
• Well versed with ANSI X12, HIPAA, Medicare and Medicaid standards.
• Knowledge of HIPAA Regulations and Claims Processing with good knowledge of Health Insurance Plans, Medicaid, Original Medicare and Medicare Advantage Plans as per CMS with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Followed the Agile methodology and extreme programming concepts of project development.
• Efficient in MS Project/MS Excel for planning/status reporting/writing test scenarios.
• Worked extensively on Business Requirements, Functional Specification, Data-Integration, Data Mapping, and Data Warehouse access using SQL, ETL process, use cases modeling (UML) using MS Office (Word, Excel, Access, Visio) and dashboards
• Skills in developing Use Case diagrams, Sequence diagrams, Activity flow diagrams, and Entity Relationship diagrams.
• Good knowledge of FACETS Member, Provider and Claim module involving Configuration, Customization, Reporting, Analysis and Enhancement.

TECHNICAL SKILLS

Business Tools: MS Office Suite, MS Visio, MS Project, MS Access

Methodologies: Waterfall, Scrum, Scaled Agile Framework (SAFe), Kanban, RUP

Database Tools: Oracle SQL Developer, SQL Server, UNIX, Teradata

Test Management Tools: Quality center/ALM, QTP, SOAP UI, JIRA

PROFESSIONAL EXPERIENCE

Confidential

Business System Analyst

Responsibilities:

• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.
• Directly Involved in writing Test plans, Test cases and responsible for executing the Test Scripts.
• Responsible for designing, developing test plans use cases and executing test scripts.
• Performed Smoke, Integration, functional, Regression, and system testing.
• Interacted with Business users and Technical team in providing clear solutions to requirements.
• Involved in testing HIPAA EDI Transactions and mainly focused on PA and Eligibility Transactions.
• Worked Extensively with Inbound 837 I and 837 P, 835s(Out bounds) claims processing systems
• Used SharePoint to store document and version control.
• Well versed with Claim processing from point to point.
• Involved extensively in testing of the application both manually as well as using the required tools.
• Work with solutions/delivery teams to implement data quality processes during acquisition, ETL, and delivery stages for Business Intelligence solutions and changes to Data Warehouse.
• Performed Back End Testing by executing SQL queries.
• Tested processes related to Member enrollment, Member Eligibility, Claims, Utilization management.
• Checked the data flow through the front end to backend and used SQL queries, to extract the data from the database.
• Extensively involved in Database testing by writing .Queried databases using SQL to validate data.
• Involved in designing the integrated Data Warehouse for the company to store the data from the OLTP systems.
• Created data mapping documents based on client specifications which involved working with Facet claims, membership and plan data model.
• Extracted data from excel/SQL and developed interactive dashboard and BI report using Tableau and
• SSRS for providing business insights
• Generated on-demand and scheduled reports for business analysis or management decision using SQL Server
• Organized and facilitated meetings with the management and development teams.
• Performed UAT, regression testing on EDI 835 and 837 X12formats in Facets.

Confidential, Tampa, FL

Sr. Business System Analyst

Responsibilities:

• Facilitated Joint Application Development (JAD) sessions, as well as conducted interviews of appropriate business/technical stakeholders.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Created UML Diagrams using MS Visio corresponding use cases to better explain the ‘TO-BE’ and ‘AS-IS’ process to the business
• Analyzed data coming from different Data Sources.
• Process Mapping, Gap Analysis & setting up Processes across different vertical.
• Worked as a team in understanding & documenting the system logics needed to operate the claims on the new operating system.
• Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• Played key role in System Development Life Cycle Process consisting of: Design and Gap Analysis, Business Requirements, Systems Requirements, Test Criteria, and Implementation to have the outputs of project dealt with the automation of correspondence directed to Insurance policy owners.
• Created the test scenarios for the various applications like Connecture, Edifecs and Facets data integration for the End to End testing.
• Prepared the business requirement document (BRD) and system requirement document (SRD).
• Worked with Facets software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPPA transactions and facilitate the administration of HIPAA privacy rights.
• Worked on developing the business requirements and use cases for FACETS batch processes; automating the billing entity and commission process
• Demonstrated a high-level understanding of how health insurance business works
• Gathered requirements and delivered to the team via epics, features, and stories in JIRA.
• Used the Agile methodology to build the different phases of Software development life cycle (SDLC).
• Created the Test scenarios condition for the online enrollment and HIX (CMS Health Insurance Exchange) group/member by uploading EDI X12 834 file to Edifecs for the HIPAA Validation and integrate the data in Facets.
• Perform root cause analysis, document action plans and provide organizational feedback.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Developed SQL queries, functions, stored procedures and triggers to perform the backend testing of the data.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams and data flow diagrams using UML and Business Process Modeling.
• Elicit requirements from various sources to create business and functional requirements documentation.
• Responsible for Data Profiling to determine data integrity for transformation of Data from Source to Target.
• Migrated Data from MS Excel to SQL Server Reporting Service Using DTS and SQL loader utilities.
• Worked intensively on enrollment (834), billing and finance related projects.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Created DTS Packages for migration of data between MS SQL Server database and other databases like MS Access, MS Excel and Flat Files.
• Designed and developed dashboards and data visualization that helps to make informed business decisions using Tableau and excel.
• Responsible for Data modeling and Mapping through data analysis to extract data elements from various OLTP’s using ETL technique and utilized Business Intelligence Tool (Tableau) for report generation.
• Developed SSIS packages for ETL to migrate data from different sources including insurance groups etc to the data Involved in FACETS configuration, Customization, reporting, analysis and enhancement and worked on membership, claim module, Batch Processing, Pricing Module.
• Conduct system integration and user acceptance testing to ensure accuracy is met.
• Communication & Coordination with a wide group of stake holders, including Directors, mapping requirements and coordinating in developing and implementing processes in line with pre-set the guidelines
• Worked on Enrollment, Claim, Billing, and Membership module of FACETS.
• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Performed Data mapping on the extracted data, logical data modeling, created class diagrams and ER diagrams.
• Designed and developed Use Cases and Use Case scenarios, Activity Diagrams, Sequence Diagrams, High Level and Low-Level Process Flow Diagrams using UML and Business Process Modeling.
• Responsible for creating test case scenarios, creating test data plan and writing test scripts for the UAT using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Experience in working in agile and spiral and waterfall model.
• Reviewing deliverables for ensuring quality and traceability
• Identification of testing scenarios and providing direction to testing team.
• Performed White box testing for Web-Services testing.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 837/835 transactions.

Confidential, Chicago, IL

Business System Analyst

Responsibilities:

• Gathered Business Requirements from different business owners such as Claim, enrollment, cost containment, marketing, customer service etc.
• Involved in gathering the requirements that were critical to the business process flow and using those requirements for the Business Requirements Document (BRD)
• Conducted JAD sessions with Subject Matter Experts (SME’s) to obtain domain level information, interviewing and asking detailed questions and carefully recording the requirements in a format that can be reviewed an understood by both business and technical team.
• Prepared high-level logical data models and Business Required Document (BRD) and supporting document containing essential business elements, detailed definition and description of the relationship between the actors.
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider claim processing, etc.
• Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
• Demonstrated a high-level understanding of how health insurance business works
• Analyzed business requirements and organized high-level and low-level Use Cases.
• Adapted UML standards to define modularized Data Process Models.
• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD.
• Worked on the Edifecs Transaction Manager for validating the in-bound and Out-bound Transactions by checking the compliancy and sending acknowledgements to the corresponding Trading partners.
• We were also working for facets migration/conversion from one version of facets to another higher version and from one environment to another environment.
• Supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Gathered and documented functional requirements for testing and verification of HIPAA.
• Involved in the full 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), 997 and 999 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Created process flow diagrams describing provider and member access to the web portals.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and the performance of the application from various dimensions.
• Worked on claim processing module which involved Receipt and Verification of Claim Forms (837) and Claims Adjudication, Health Claim Payment/Advice (835) as per HIPAA guidelines.
• Designed and implemented basic SQL queries for reports and data validation.
• Involved in end to end testing of Facets Billing, Claim Processing and Subscriber/Member module.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application
• Include Business rules in System Use case document to identify claims, membership, Billing etc.
• Created Business Requirement Documents as a result of meetings with the Business Areas. Obtained business sign offs on the documents after reviewing the final documents with them.
• Assisted in creation of the Functional Design Document from the Business Requirements Document which was used as the reference by the development team while preparing the design and held the responsibility of the required data setup for unit testing.
• Created and maintained SQL scripts and UNIX as a part for backend testing on the oracle database.
• 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.
• Create SQL queries to read data from databases.

Confidential

Business System Analyst

Responsibilities:

• Working with clients to better understand their needs and present solutions using structured SDLC approach.
• Participated in creation of Business Process Workflow Diagrams with Stakeholders.
• Conducted meetings with business users and SMEs to identify and gather various functional and non-functional requirements.
• Analyzed business requirements and organized high-level and low-level Use Cases.
• Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures to create a Business requirement Document (BRD).
• Conducted GAP analysis of the different reports that are being presented to clients to accommodate their requirements.
• Good understanding of MMIS Business Process Model.
• Participated in creation, structured content, designed sites and was a super user in SharePoint 2013 & Office 365.
• Familiar with the end to end business process in Provider Management and Member Management in MMIS.
• Worked on Benefit Plans, Claims Payment Cycle, Waiver Programs and Reference, Obama Care, Affordable Care Act (ACA) Applications, Facets configuration, Billing applications, Life Insurance Application, Managed Care Organization system, Epic applications, MMIS, Medicaid and Medicare claims and Eligibility processing systems.
• Worked closely with business and IT folks along with SME’s to amend, create, and updating process flow charts from “AS IS” to “TO BE” system.
• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus.
• Updating and maintaining RAID - Risk, Assumptions, Issues and Decision log and assist Project Manager in overall project work efforts.
• Involved in Facets Implementation, including end to end testing of Facets Billing, Claim Processing and Subscriber/Member module.
• Utilize SNAP/TANF/Medicaid program policy knowledge to translate technical requirements and specifications.
• Worked on Eligibility for State Welfare Children’s Health Insurance Program (S-CHIP), Child Care and Temporary Assistance to Needy Families (TANF) (CHIP, SNAP, TANF)
• Create process flow and walk team through on the conference call/meeting and get signed off by the product owner
• Worked on Claims, Customer services, Members, Billing-Enrolment interfaces and extensions for FACETS as a part of FACETS implementation team.
• Finding and documenting GAPs between legacy system vs new system and communicate with the business and IT.
• Executed Testing Scenarios, Cases & Conditions involving User Acceptance testing, Regression, Integration and System testing.
• Worked on different EDI transactions like 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270/271 for Eligibility inquiry, and 276/277 for claims status.
• Helped migrate SharePoint 2007 and 2010 to SharePoint 2013 and the cloud.
• Developed Data Mapping and Crosswalk documents.
• Involved in preparing several Use Cases, BPM, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Conducted PM-BA forum on bi-weekly basis for open discussion on project works and interdependencies
• Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrollment and benefits, batch jobs corresponding to the claims (837) and real time transactions like 270/271/276/277.
• Worked in testing the professional, institutional claims processing and adjudication and validate data with facets.
• Assisted in Regression Test, System Test, and UAT (User Acceptance Testing)