SUMMARY

• Over 9+ years of diversified experience in Business Analysis, Implementation and Quality Assurance of web based and client server applications using n - tier architecture with knowledge of the Software Development Life Cycle and Quality Assurance Life Cycle.
• Worked extensively with large payer organizations, including the work on process improvements for HIPAA Compliance
• Superior knowledge in Privacy and Security Regulations for HIPAA
• Excellent understanding of HIPAA transactions and code sets.
• Experience in gathering and interpreting the requirements to prepare the business requirement document and functional requirement document for major healthcare claim processing enhancements
• Extensive Experience in Requirements Analysis using Waterfall, Rational Unified Process, Agile and Extreme Programming Methodologies.
• Extensive knowledge and experience identifying user’s needs and translating those into functional specifications using structured methodologies and tools.
• Excellent problem solving and conflict management skills including the ability to manage conflict and find mutually acceptable resolutions.
• Advanced Use Case Modeling Techniques: Include, Extend, and Generalize.
• Proven configuration skills of Trizetto FACETS: enrollment, claims, claims reconciliation, provider, member, benefits, billing.
• Worked on Data migration, Facets version upgrades, Reports Implementation, letters, Inbound/outbound Interfaces and Facets Extensions. Experience in implementing EDI transactions 835, 270/271, 276/277 and 834.
• Advance System Analysis skills, expert in writing functional specifications.
• Strong analytical skills to identify and resolve problems with the system and ability to effectively apply a broad range of professional concepts, practices and methods in moderately complex and diverse circumstances.
• Experience with health care systems: 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.
• Extensive experience in documenting the Business Process in accordance with the Business needs.
• Expert in Functionality, Regression Testing and Compatibility Testing
• Solid experience with ICD 9 and/or ANSI in Health Care and strong understanding Facets and NASCO Claim processing.
• Experience in integration of various data sources like Oracle, MS SQL Server, XML and flat files into the staging area.
• Expertise in writing design documents; Data Design, Architecture Design, Interface Design, and Procedural Design.
• Experience in developing functional specs through JAD sessions and user interviews.
• Actively involved in developing, executing, and managing User Acceptance Testing (UAT).
• Strong experience in documenting existing process, analyzing business requirements, working with requirements traceability matrix, re-engineering business processes and designing.
• Efficient in MS Project for planning and status reporting.
• Ability to handle multiple tasks and work independently as well as in a team.
• Ability to meet deadlines and handle pressure coordinating multiple tasks in project.
• Both a strategic and tactical mindset to enable the development of a general high-level design and to enable detail reviews of Technical Detail Designs
• Team player and self-starter with excellent communication, coordination, documentation, project planning and interpersonal skills.

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, Erwin, Enterprise Architect

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

Testing Tools: HP QC, HP ALM

Languages: SQL, HTML, CSS, XML

Reporting Tools: Tableau Desktop, 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, IBM WTX, EDIFECS

Databases: MySQL, IBM DB2, Oracle

PROFESSIONAL EXPERIENCE

Confidential

Lead Business System Analyst

Responsibilities:

• Involved in the meeting with Business process owners, SMEs and marketing team for Requirements gathering in definition stage.
• Converted Business specifications into Functional Specifications.
• Worked with State and Business to gather 837 Maternity Claim event requirement and proposed design that can generate State compliant 837 Claim file
• Worked on Member Coordination of Benefits (COB) Accumulator configuration related to Benefits tables in Members.
• Design and development of inbound and outbound maps.
• Worked as a Business System Analyst interviewing client to understand their business and functional requirements, gathering their future needs, and transforming them to functional specifications.
• Worked with Blueprint requirements center system by defining business requirements by sketching business process to give everyone clear vision of application purpose.
• Responsible for mapping data attributes from existing client sources to the target reporting data model.
• Mapped data elements from multiple legacy databases to a new consolidated target database.
• Worked closely with Providers to gather requirement for Provider Subsystem.
• Wrote Functional Requirement for configuration of Benefits, Provider and Claim processing.
• Worked on PCP Relationship which connects Provider and Member tables and Modules.
• Worked on Provider Entity Relationships which configured on FACETS Application.
• Worked on setting up provider Group and IPA’s in FACETS.
• Prepared a package of Process flow diagrams to document the existing system.
• Worked on Configuration of Benefits with Enrollment and Claim processing systems. Also configure Coordination of Benefits calculation methods, Charges, Facets allowable, Higher allowable, another carrier allowable.
• 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
• Performed activities to comply with annual HEDIS data collection and analysis, preparing recommendations to increase rates as appropriate
• Tested HIPAA Transactions and Code Sets Standards such as 837/835, 270/271, 276/277 transactions.
• Wrote Functional Requirement for configuration of Benefits, Enrollment and Claim processing.
• Worked on Configuration of Benefits with Enrollment, Membership and Claim Processing system.
• Worked on Process Flow Models and Captured Process flow diagrams.
• Worked on the Benefits Messages which user has specified that on a claim involving Coordination of Benefits.
• Configured benefits EOB imports batch job which populates EOB table stores the EOB (Explanation of Benefits) amounts information.
• Worked on configuring 80 plus plans and 350 plus variations and wrote business rules for loading the benefits into FACETS.
• Wrote requirement document for Data Extraction, Data Analysis and Loading process.
• Performed data integrity and data validation by writing SQL queries in SQL Navigator.
• Worked on EDI transactions like 270/271, 276/277, 835/837 and EDI’s. Worked on Use Cases for Batch processing for EDI’s.
• Involved in Writing use case based on HIPAA standards.
• Used UML/RUP to develop requirements and architect a solution.
• Responsible for creation of Collaboration Diagrams, Activity Diagram, Project Flow Diagram in MS Visio.
• Gathered Requirement from the Client to fulfill the Application need for FACET Implementation.
• Prepared Use cases, Sequential Diagrams with detailed screen layouts with regards to various types of corporate actions.
• Extensive Analysis of HIPPA rules to incorporate in the Development of Utility application which is not HIPAA compliant.
• Wrote Test Cases and Test Plans for Testing HIPAA Transactions and Code Sets Standards such as 837/835, 270/271, 276/277 transactions.

Confidential

Business System Analyst

Responsibilities:

• Interacted and arranged meetings with Business and End users to gather business requirements for configuration of Benefits with various other systems.
• Elicited and documented business requirements, perform data and transaction mapping, complete a GAP analysis, and document the impact of the migration from HIPAA 4010A1 to HIPAA 5010 on current business processes and applications.
• Analyze current business processes and systems to provide business process improvement ideas.
• To ensure minimal impact to business continuity, planed for a batch-wise transition of trading partners from HIPAA 4010 to 5010. Created Use cases for 820 (Premium Payment) and performed gap analysis and impact analysis for the 820 transaction 5010 changes.
• Worked on 837 and 835 projects, including syntax and business rules for X12 HIPPA 4010 and 5010 validation for loops, segments, elements, qualifiers, and code set.
• Resolved issues with the EDIFECS, primarily the generation of 997, 999, 824, 277CA reports.
• Compared and Validated 5010 test results with 4010 results for the same test scenarios.
• Responsible for ensuring HIPAA EDI Trading Partner transactions meet established standards and can be transmitted and processed.
• Also Performed Web Portal testing 270/271 and 276/277.
• Create the HIPAA EDI 834 file sending HIPAA data to providers
• Created X12’s for 4010 and 5010 standards to meet test case scenarios.
• Manage test file trading with external Trading Partners (Clients / Payers, Providers, Clearinghouses)
• Analyzes business and user needs, documenting requirements and revising existing systems.
• Carried out Gap analysis and assessment to out to identify the comprehensive impact of HIPAA 5010 to processes and systems. Based on the assessment, detailed requirements should be gathered around how systems and processes will need to be modified to achieve compliance.
• Develop and recommend operational processes and/or process improvements in support Facets clients.
• Document business requirements for changes required to conform to the Trading Partners Companion Guide.
• Gathered the business requirements and prepared the analyzed data/workflows for business users.
• Lead the impact analysis, scope lockdown, and requirements gathering phases of the company's transition from ICD-9 to ICD-10 and development phase management of transition from HIPAA 4010 to HIPAA 5010.
• Performed System and regression testing using a simulator that can generate 5010 transactions from 4010 transactions.
• Write data mapping documents and performing gap analysis on the systems.
• Analyzed business needs and created Business Requirement Document (BRD) Application Use Case (AUC) documents for business and end user review.