SUMMARY:

• Over 8 years of Experience as Business Analyst in Healthcare include understanding of Business Requirement Gathering, Business Analysis, Joint Application Development JAD sessions with clients and referring to accessible documentation and procedure.
• Functional Knowledge of Medicaid Management Information System MMIS .
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Extensively Knowledge in the Member Enrollment and Billing information.
• Knowledge and Experience on Membership, Billing, Claims Payment Processing in relation to HIPAA, EDI 4010, 5010 X12, ICD-9 ICD-10, codes 834, 837,835, and 270, 271.
• Strong knowledge of ICD-9/ICD-10 business analyst with healthcare.
• Able to understand and implement Processing ICD-9 ICD-10
• In dept. knowledge of Software Development Life Cycle SDLC methodology such as Agile, Waterfall and RUP .
• Efficient in writing Business Requirements Document, Use Case Specifications, Functional Specifications and Workflows.
• Strong knowledge of Use Cases, and Activity Diagram.
• Involved in Facet Implementation and conversion of 4.21
• Extensive Experience in Functional, Integration, Regression, User Acceptance UAT , System.
• Knowledgeable working with ETL process Extract, Transform and Load of data into a data warehouse.
• Designed and implemented basic SQL queries for testing and report/data validation
• Experienced in client interaction, deep understanding of business systems functionality and technicality.
• Proficient in Developing and executing Test Plans, Test Case, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
• Knowledgeable about preparing RTM documents
• Experience in developing project plan and estimating project timeline.
• Excellent working knowledge in Project Life Cycle and clear understanding of Project Management.
• Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements.
• Excellent business communication and presentation skills. Adapt at creating, editing, and coordinating extensive communication networks, to keep executive staff and team members apprised of goals, project status, and resolving issues and conflicts.
• Conducted successful projects with the help of teams to achieve deadlines timely and proficiently.
• Organized, goal-oriented, self-starter, and ability to master new technologies manage multiple tasks while following through from start to completion.
• Experienced in analyzing business requirement at all stages of Software development of life cycle SDLC .

HEALTH CARE DOMAIN EXPERIENCE

• Good knowledge on different modules within healthcare Membership, billing, enrollment, claims, capitation, providers .
• Experience with HIPAA compliance and Healthcare systems.
• Clear understanding of ICD-9-CM and ICD-10-CM/PCS
• Experience handling HIPAA ANSI X12 270/271, 834, 835, 837, 276/277 , ICD9/10, NDC, DRG codes.
• Experience providing primary analysis for business processes running on the EDI Electronic Data Interchange standard.

Technical Tools:

Confidential

Business Systems Analyst

Confidential has to comply with CMS mandated ICD-10 requirements within very tight deadlines. The scope of the project is to collect the detailed information from various areas of the hospital and gather the requirement regarding all the applications, which are currently in use in hospital. The purpose of the project is to define the roadmap for implementation and analyze the collected data in order to fulfill the change from ICD-9 to ICD-10.

Responsibilities

• Perform a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
• Have strong experience in requirements gathering by conducting interviews with end users
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Extensively worked on Data Mapping and ETL.
• Analyzed System flows of various department of the hospital.
• Identified risks, problems, requirements and concerns of the Hospital in order to comply with ICD-10 changes. 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.
• Highly involved in understanding of department workflows and process flows with respect to applications. Developed business process models in RUP to document existing and future business processes. Improved process for payment of Medicare Secondary Payer claims through revised workflows.
• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
• Wrote SQL queries/joins for Oracle database and prepared test data.
• Designed and developed user interface screens for visualization of reports and various user inputs with cross-functional teams.
• Re-Organized the collected data and prepared documentation for implementation.
• Involved in providing education about the ICD-10 codes and 5010 standards, its requirements, complexity and accuracy to Physicians and Nurses of the hospital. Figured out the requirement of training in various departments of the hospital based on their daily work.
• Performed impact analysis on applications for deadliness of ICD-10 conversion.
• Responsible to meet the information demands of our business users by delivering timely, accurate, meaningful and standardized data and reporting.
• Mapped the collected data with the existing data provided by the hospital departments.
• Used Word, Excel and Visio as a working tool.
• Hands-on experience and good understanding of the hospital working system including Registration, Scheduling, Radiology, Laboratory, Pharmacy, Patient Accounting, HIM, Claim Processing etc.
• Met the deadlines and scheduled day to day meeting sessions.

Environment:

Windows 2007, Packet Tracker, MS office suite, MS Visio, UML, RUP SDLC , MS SQL Server.

Confidential

Sr. Business Analyst

The goal of the project was the development of a state of the art web-based technology re-engineered from a legacy database technology, including the business Functions. The project involved re-engineering of the existing billing System along with achieving HIPAA compliance. The deliverables in the project included core billing functionality and standard reports.

Responsibilities:

• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Gathered high-level requirement for all the external projects in a release.
• Performed the requirement analysis, impact analysis and documented the requirements.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Worked on EDI transactions: X12,835, and 837 P.I to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes
• Involved in Able to understand and implement Processing ICD-9 ICD-10
• Documented ICD9 to ICD 10 mappings one to one/one to Many according to the GEM files from CMS with the functional and structural changes related to the conversion
• Created ICD-9-CM/ICD-10-PCS comparison document and dealt with DRGs.shift through CMS files.
• Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Performed Analysis on Data mapping between different data models.
• Developing a single application to process data from multiple integration points, convert the data for reporting purposes and feed data into mainframe system to be compliant to reporting requirements.
• Executed the test cases and test scenarios using HP Quality center QC .
• As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.
• As Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming session, daily scrums product demos, sprint reviews and sprint retrospectives.
• Prepared Business Requirement Documents BRD's after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any .
• Created various reports such as billing payment reports, Billing Grouping Payment and discount reports
• Use HP Quality Center to house all test documentation and report/track all issues and defects Defect Management .

Environment:

Rally, MS Visio, HP QC, UML, MS Office, Agile Scrum, SSRS

Confidential

Business Analyst

Enterprise Project Management EPM is a process that coordinates projects across the enterprise and provides project management guidance to all agencies. The goal was to achieve the best practices to maximize project successes and leverage expensive project expertise resources, provide expertise and support to project managers, provide ongoing process improvement approaches that, over time, will provide an even greater chance for successful projects

Responsibilities:

• Involved in all phases of software development life cycle SDLC in RUP framework.
• Analyzed and collected business requirements, identified system interfaces and created the requirements specification document.
• Facilitated JAD sessions to gather requirements.
• Applied Unified Modeling Language UML methodologies to design Communication Diagram, Use Case Diagrams, Activity Diagrams, Sequence Diagram and ER diagrams.
• Extensively interacted with both user group and development team.
• Worked MS Office products including MS Excel, MS Access and MS Word.
• Managed and tracked change control process of requirements and design changes. Documented the changes, issues and their impact on the system design and delivery.
• Provided documentation such as requirements management plans, functional requirements, test plans and test cases.
• Worked extensively to produce reports using crystal reports.
• Incorporated the best practice methodologies as advocated by the Rational Unified Process.
• Designed and analyzed Business Process Model, Use Case model and test procedures based on RUP methodology.
• Performed requirement analysis by gathering both functional and non-functional requirements based on interactions with the process owners stake holders and document analysis. Performed user interviews.
• Wrote user requirements specification URS and Functional requirements specification FRS
• Documents as per the Business requirements and process flow.
• Designed and developed project templates based on SDLC Methodology.
• Developed UML Use Cases for the application and prepared the detailed Work flow diagram based on the proposed enhancement for the system.
• Developed modules in the HR department for educating and training the user about the new system.
• Functioned as the primary liaison between the business line, operations, and the technical areas throughout the project life cycle.
• Performed task decomposition, delegated tasks and monitored project milestones using MS Project. Created test cases and test scripts.
• Conducted User Acceptance Testing UAT , Unit testing and System testing.

Environment:

Oracle 8x 9i, Asp. Net, MS Project, MS Office Suite, RUP, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS office suite 2003, MS Visio 2003.

Confidential

Business Analyst

Confidential is a company providing customers with benefits, expertise and service that improves the health, well-being and productivity. I performed pivotal role in multiple projects handling three releases at the same time. Release 1 2 was web-based service application developed for streamlining office workflow processes involved in Electronic Data Interchange EDI transactions and benefits in claims management cycle based on HIPAA Guidelines. Release three was based on reporting the policy premium. There were seven reports, which were generated in Brio portal.

Responsibilities:

• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Planned and defined system requirements to Wire Frames with Use Case, Use Case Scenario and Use Case Narrative using the UML Unified Modeling Language methodologies.
• 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 the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 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.
• Prepared Business Workflow models that cover How business processes are accomplished.
• Upgraded HMO Medicare EDI and reporting.
• Gathered requirements and modeled the data warehouse and the underlying transactional database
• Created Source to target data mapping documents identifying key data elements and prepared Data Flow Diagrams
• Developed the Schema Crosswalks for 837 P, I, D , 835 and 276/277 according to HIPAA implementation rules.
• Assisted the database development team in data modeling, data structure and data table layouts required for consolidation of incongruent databases,
• Addressed the changes made to the Medicare program and created requirements mapping to that of the system requirements.
• Created Functional specifications for the 834 enrolment files with their changed benefits in the Medicare program.
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access.
• Prepared questionnaire based on the System Analysis Performed for all entities.
• Worked on System Integration X12 EDI-HIPAA-835 with Health plans eligibility and claim CPT, ICD 9 codes .
• Followed the UML based methods using Rational Rose to create: Use Cases, Activity Diagrams/State Chart Diagrams, Sequence Diagrams, and Collaboration Diagrams.
• Linked business processes to organizational objectives, perform critical path analysis, and identify opportunities for business process improvement.
• Assure that all Artifacts are in compliance with corporate SDLC Policies and guidelines
• Automated Shell scripts to pull and load data from operational resources into the Data Staging Area and Data Warehouse for business intelligence reporting
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Conducted user interviews, gathered requirements, analyzed the requirements by using Rational Rose, Visio and Requisite pro - RUP
• Gathered and validated requirements, resulting in detailed business rules, functional requirements and process design.

Environment:

Ascential Data Stage 7.5, Designer, Director, Manager, Parallel Extender Debugger, MS Word, Excel, Visio, Access, and Project, Star Schema ,UNIX, Mercury Test Director Agile, Waterfall

Confidential

Business Systems Analyst

• DHHS handles the Medicaid claims payment and Primary Care Case Management administrator duties for the state of Nebraska. It is dedicated towards helping low income families, children and elderly people to improve their health, well-being and security. The scope of the MMIS HIPAA 5010 Transactions Project is planning, analysis, design, development and implementation required to implement the mandated HIPAA ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0 electronic transaction standards in the Nebraska legacy MMIS. The approach to the remediation of the legacy MMIS is to meet the minimal functionality necessary to electronically send, receive and process the HIPAA compliant standard transactions.
• As a member of Business System Delivery BSD team, I'm engaged in providing support through the entire lifecycle to multiple projects involving web service and user interface development and covering Provider Dental/Medical/Behavioural , Claims Medical/Dental and Reimbursement Processing domains. Working on Healthcare Web Portal product that will be developed such that the portal can interface with the Medicaid Management Information System MMIS maintained for the State of Nebraska. The interface work to the MMIS will be performed by the Nebraska account team. The Healthcare Web Portal product will offer an ability to provide a consistent look and feel to the client's existing Web presence so that the client can offer visually seamless transitions from their existing portal to the portal product. The new proposed system will be packaged and integrated with the existing product.

Responsibilities:

• Responsible for implementation of 4010 to 5010 transition in compliance with new HIPAA standards.
• Identified and involved with all key stakeholders, contributors, business, operations and technical resources that must participate in projects and ensure that contributors are motivated to complete assigned tasks within the parameters of the project plan.
• Responsible for coordinating Joint Application Development JAD sessions with business users, technical team, DBAs, testing team to analyze and validate the requirements, application lifecycle, gather and define the key performance indicators, document and present the requirements specifications.
• Authored business requirements and conduced User Interviews to identify and document the data discrepancies and their sources as related to Government Contract Compliance GCC , Government Disclosures, Government Pricing, Customers, Products, Product pricing.
• Involved in performance testing of Medicaid client server claims processing system, Medicaid MCC / MCO and Medicaid Management Information System MMIS
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Created 837 I, P D claims using macro enabled claim spreadsheets. Created and maintained data mapping document s in reference to the HIPAA transactions: 270/271, 276/277, 837, and 835.
• Organized and documented Use Cases, Business Rules and Functional Requirements for all system functionalities. Maintained traceability GSD and DSD through updates to RTM.
• Identified testing scenarios and defined test cases for detailed functional testing.
• Planned and documented NPI CrossWalk procedure including NT Z into the provider database. Also Conducted Risk assessment for NPI touch points to determine how the NPI upgrade affects the legacy system and the third party.
• Analyzed the requirements of NPI with Health Care Providers and atypical providers to identify themselves in health care transactions identified in HIPAA or on related correspondence.
• Ensured smooth claims processing while passing 837 claims for compliance check and running through load processing.
• Analyzed business scenarios to track possible business outcomes for the functions which could be incorporated into more detailed test scripts.
• Performed In-Depth analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
• Established questionnaires and resource levelling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Deployed Business Intelligence solution using Business Objects to ensure proper delivery of information to the users and Oracle Projects Suite for proper Project Management.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process
• Performed workflow analysis toward automated disability claims process.
• Responsible for Lotus Notes Server maintenance, configuration and troubleshooting on the UNIX Server.
• Documented Requirements for Management Reporting out of Clear Quest using Crystal Reports.
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Coordinate with the end users in doing the UAT and developed manuals testing. Executed test scripts, co-ordinate and conducted System and UAT testing.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database
• Conducting requirement sessions and successfully translating of those requirements into Use Cases and GUI wireframes.
• Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and Use Case Narrative using the UML Unified Modeling Language methodologies.

Environment:

Windows 98/2000, Window2003, Window NT, Linux, Mainframe, Solaris IBM Web sphere, NDM FL , Ultra Edit, Clarity, File Viewer, Lotus Notes, Apache Tomcat, IIS 6.0, Web Logic, Java, SharePoint, MS Office Suite, Quick Test Pro 8.2, Mercury Quality Center 9.0, NDM-Server, Load Runner 8.2, Sun Java, MSJVM, Oracle 8i/9i/10g, SQL Server 2000, DB2, Toad, MS-Project 2000/2003.

Confidential

Business Analyst

Confidential is confidential based health insurance and maintenance organization. Provide payment and Primary Care Case Management administration duties to the State of New York. It was formed in 2006 by the merger of Group Health Incorporated GHI and HIP Health Plan of New York to become a profitable company. I'm engaged in providing support EDI UAT testing team conducting different test and Comprehensive understanding of Quality Center Defect Module, which supports the entire defect lifecycle from initial problem detection through fixing the defect and verifying the fix.

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Worked with the business users and with different levels of management to identify requirements, use cases and to develop functional specifications.
• Identified, researched, investigated, analyzed, defined and documented business processes
• Created Business Requirement Document BRD , Functional Requirement Specification FRS document, User Requirement Specification URS and Change Request CR document for system application development.
• Owned the entire reporting process. Interacted with the ETL team, developer s , management, and account holders to get the requirements, document them, design templates, and write specifications.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Managed changing requirements which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Trouble shoot file transmission problems and assisted customers with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides 837P, 837I, 837D, 270/271 .
• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Obtained Data requirements, identified data sources, determined the content of data fields and created Data Mapping Documents and performed Data Extraction and Data Compilation using SQL queries.

Environment:

MS Visio, Excel, MS office, Rational Rose, Dreamweaver, Rational Unified Process RUP , ETL, Agile, SQL Server, Informatica