SUMMARY

• Over 7 years of Experience as Business Analyst in Healthcare include understanding of Business Requirement Gathering, Business Analysis, with clients and referring to accessible documentation and procedure.
• Solid experience in understanding of all phases of Software Development Life Cycle (SDLC) methodology (such as requirement, analysis, design, data modelling, business process modelling, implementation, and deployment).
• In dept. knowledge of Software Development Life Cycle SDLC methodology such as Agile, Waterfall and RUP and Efficient in writing Business Requirements Document, Use Case Specifications, Functional Specifications and Workflows and Strong knowledge of Use Cases, and Activity Diagram.
• Extensive experience in gathering Business/Functional user requirements, creating Use Cases as per user requirements, developing/designing diagrams such as Activity, Class, and or Sequence diagrams, and in addition to creating Business Requirements Document (BRD).
• Extensive experience in conducting Joint Application Development (JAD) sessions for project definition involving analysing requirements, creating prototypes, user interface, database schema and system design.
• Experience in understanding of EDI business practice and the ability to understand the client's needs.
• Expertise as acting a liaison between the internal and external business community (Claims, Billing, Membership, Customer service, membership management, provider management)
• Extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, System, Medicare and Medicaid, CMS Compliances/Regulations
• Experience in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Strong institutional knowledge of Medicaid; including Medicaid Information Technology Architecture (MITA), and Medicaid Management Information Systems (MMIS)
• Experience in development of 820, 834, 837 Claim billing, 276 Status, 834 Enrolment, 835 Claim Payments, 829 and many other healthcare maps.
• Experience in Electronic Medical Record (EMR) / Electronic Health Records (EHR) modules and process flow.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Experience on Membership, Billing, Claims Payment Processing in relation to HIPAA, EDI 4010, codes 270, 271.
• Experience in working on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Experience in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Experience in lending the team of Business Analysts for creation of Business and Functional Requirements for the creation of Electronic Health Records (EHR).
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid, and Medicare.
• Experience in HIPAA related EDI development for 837, EDPS, 835 and other EDI processes using Pervasive EDI translator.
• Experience in writing BRD, TSD, Mapping doc., test scenarios, test cases for testing the functional and non - functional aspects of both ETL and Reporting jobs.
• Experience and knowledge of EHR/EMRs Electronic Medical Records, HL7 and its Confidential Protection and Affordable Care Act PPACA .
• Experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS/RAPS).
• Experience in working on the screenshot and prototype development for the various online screens meant for the EHR project.
• Experience in sales and marketing specializing in practice management, managed care systems, thin-client technology, Electronic Media Records EMR/EHR/PHE/PMR, ASP technology, and full integration tools.
• Experienced with Federal contracts, X12 transactions, health care act, EDI transactions 270, 271, 834, 835, 837.
• Excellent experience in developing and executing Test Procedures, Test Cases, Test Scripts, Test Plans, performing Functional Testing, Compatibility Testing, Usability Testing, Stress Testing, UAT.
• Knowledge in the ETL (Extract, Transform and Load) of data into a data warehouse/data mart and Business Intelligence.
• Experience in writing Sequential Query Language SQL and a good understanding of Relational Database Management System RDBMS concepts
• Expertise in Medical software application (EMR, IDX) for hospital workflows and setting up the infrastructure for a software implementation in a clinical environment.
• Experience in understanding of developing reports, dashboards, and processes to continuously monitor data quality and integrity on Salesforce.
• Expert in Test driven development & Unit testing methodologies for performing UAT, System Integration testing (SIT), and Business Acceptance Testing (BAT).
• Participated with QA team in different phases of testing such as System testing, Functional testing, Regression testing and Integration testing for Quality Analysis.
• Excellent skills in Business Analysis, Data Analysis, Requirement Analysis, Business Modelling and Use Case Development using UML methodology.

PROFESSIONAL EXPERIENCE

Confidential

Business Analyst

Responsibilities:

• Involved in performing SWOT and Gap analysis for the new functionality requirements.
• Developed and supported the ETL process for the data warehouse from various data sources including EDW.
• Responsible for data management, submission, and reconciliation as well as analysing and reporting for Medicare and Medicaid RAPS and EDPS risk adjustment programs.
• Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Functioned as a CMS point of contact for whole RAPS and EDPS claim submission process, which include tracking all claim submission, return file management, regulatory documentation distribution, maintaining clear communication etc.
• Worked on RAPS and EDPS reconciliation change requests.
• Responsible for validating claim processing transaction of MMIS.
• Worked on the ETL implementation using SQL Server Integration Services (SSIS).
• Responsible for checking member eligibility, provider enrolment, member enrolment for Medicaid and Medicare claims.
• Worked on different types of insurances such as, Group health insurance, individual health insurance, dental insurance, vision insurance, etc.
• Hosted the application online using Microsoft SharePoint excluding some functionality those were developed to use by employees only.
• Identified and documented the dependencies between the business processes and Created and executed Use cases for product and benefits testing for Medical.
• Involved in documenting the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office, and Rational Rose for a clear understanding of the requirements by the development team.
• Responsible for Medicaid Claims Resolution/Reimbursement for state health plan using MMIS and Conducted JAD sessions and Data modelling.
• Used SQL to test various reports and ETL load jobs in development, QA, and production environment.
• Involved in determine member benefits and priced claims according to individual provider's contract under Medicare CMS guidelines and Dental benefits.
• Facilitated daily scrum, sprint planning and sprint retrospectives meeting.
• Involved in Information Technology with focus on Business Analysis, Business Modelling, Requirement Gathering, Documenting Requirements (BRDs/FRDs/Use Cases), and Software Validation.
• Worked with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Responsible in testing and analysing data consolidation, organization, and presentation in MMIS.
• Involved in creating and maintaining the Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Involved in documenting all the aspects of Systems validation lifecycle in accordance with the FDA regulations, including Validation Plan and Protocol, Installation Qualification (IQ) Specifications, Operation Qualification (OQ) Specifications, Performance Qualification (PQ) Specification.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology)
• Involved in implementing the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Responsible for teaching sessions for end user to tell how to use tools and Used MS Project for various planning and budgeting activities.

Confidential, Basking Ridge, NJ

Business Analyst

Responsibilities:

• Involved in Reviewing and understand CMS regulations, data files and requirements that support Medicare D premium billing processes.
• Involved in managing the team of consultants responsible for developing on-demand Medicaid Management System MMIS reports.
• Developed and conducted Business Process Analysis for an HCM upgrade from 8.9 to 9.0 for eight healthcare facilities.
• Extensive Respond to Request for Information RFIs for external clients and prospects to the FAS business.
• Involved in leading multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, WebSphere, and Cognos.
• Involved the project with strategic change and operational improvements implemented around a PeopleSoft 9.1 HRMS application.
• Extensive Facilitated sprint planning, release planning, sprint retrospective, sprint review, and daily scrum meetings.
• Involved in demonstrating proficiency in understanding the required certificates, licensures and documents required by NCPDP and Pharmacy Benefit Managers due to contract requirements and CMS regulations.
• Extensively Acted as Scrum Master Coach and Agile QA lead for over 20 scrum masters.
• Involved in Coaching Product Owner, development team, and project stakeholders to adhere to scrum values and practices.
• Involved in giving leadership to organization to identify the ERP teams and other roles for the implementation plans.
• Actively participated in various Healthcare presales initiative for EHR applications, HIPAA 4010-HIPAA 5010.
• Involved in developing implementation guidelines and principles for practice-based clinical applications, including various practice management and EMR systems.
• Involved developing and implement change control policies and procedures for EMR template change requests.
• Actively served as firmwide support for all RFP and RFI requests. Manage RFP processes and procedures.
• Involved in guiding upper-level management in Scrum and agile development principles.
• Managed an Internal Verification Validation Project around a PeopleSoft HRMS 8.9 application at the Office of DC Pensions.
• Involved in building business requirements into the Medicare Advantage MA requirements database and created the Project Requirements Document for the three functional areas.
• Extensively Conducted sessions over MITA and practiced it. Worked over Companion guide.
• Involved in Interprets Claims Processing Business Rules, tests against MMIS functionality and translates differences into System Enhancements and/or Functional Defects.
• Conducted a crosswalk between the Billing Application and the HIPAA Implementation Guide.
• Involved in documenting Trading Partner Migration Process Flow from HIPAA 4010A to 5010 create process flow diagrams and presentation materials and monitor production and release events.
• Involved in coordinate with team members to ensure on time completion of proposals RFI, RFP, Proactive proposals, and presentations.
• Involved in working on Health Insurance exchanges HIX and analysed the data and worked with EDI NCPDP 5.1 considerations and implemented HIPAA regulations.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Involved in Investigating and evaluating the SAP HCM Payroll system and the current functionality the client is utilizing, identifying the gap and risks.
• Facilitated JAD sessions for Requirement Validation and requirement gathering for the new MMIS.
• Conducted fit-gap sessions as the PeopleSoft Technical Lead for Adventist Healthcare, a large client implementing PeopleSoft HRMS Supply Chain 9.0.
• Involved in reviewing the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Involved in producing Gap Analysis documents for HIPAA 5010.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ANSI X12 5010 formats.

Confidential , Reston, VA

Business Analyst

Responsibilities:

• Involved in associated with full HIPAA Compliance life cycle from gap analysis, mapping, implementation and testing for processing of Medicare, Medicaid, and Tri-care claims.
• Involved in the initial discovery/analysis phase for projects to determine the scope and impacts to the data warehousing systems.
• Worked with the team on FACETS claims processing system and gathered requirements to comply with HIPAA.
• Involved in producing BRDs and FRDs for RAPS and EDPS process to automate return file management process and achieved accomplished efficiency in saving processing time by 95%.
• Set claim processing data for different Facets Module.
• Involved in integration of FACETS with legacy and third-party vendor applications.
• Involved in establishing documentation for Agile methodology for implementation with a very water-fall-centric development team.
• Involved in understanding the HIPAA X12 EDI transaction 834 for enrolment and eligibility, X12 EDI transaction 820 for Payment Order/Remittance Advice, Acknowledgement transactions 999 and TA1.
• Performed analysis of enrolment and eligibility data in the XML format to determine if data is compatible with X12 data.
• Involved in creating format using Edifecs Spec builder and Note Pad ++.
• Involved in developing Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Responsible for the core activities of the test team including creating and executing test cases, analysing, and documenting results and drawing a traceability matrix to match the requirements with the final test scenarios.
• Worked on report creation skills using Microsoft SQL Reporting Services (SSRS)
• Participated in release cycles of software developed using Waterfall and Agile methodologies.
• Involved in integrating various systems with HEDIS and create design for HEDIS and other systems to pull data in HEDIS.
• Assists with TRR and MRR reconciliation, along with the investigation, correction, and tracking of enrolment transaction.
• Knowledge of health care services regulatory environment in compliance with HIPAA, MITA, MMIS and EDI
• Involved in writing SQL queries for testing and data validation.
• Extensively Develop, test, modify and manage EDI (x12 standard) maps using B2B mapping tool in the Healthcare industry.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Employed UML methodology in creating UML Diagrams such as Use Cases, Sequence Diagrams, and State Diagrams, Activity Diagrams and business process and workflows.
• Strong experience working in Software Development Life Cycle (SDLC) using various methodologies including Agile, Waterfall.
• Involved in project planning, coordination, and QA methodology in the implementation of the Facets in the EDI transaction of the claim’s module.
• Involved in evaluating and performed testing within Facets for Rejected QA Scenarios.
• Involved in working on Member Management, Eligibility, Claims and Billing modules within FACETS.

Confidential, Marietta, PA

Business Analyst

Responsibilities:

• Involved in developing business process diagram, activity diagram, sequence diagram to understand the data flow between the provider and the Payer.
• Involved in cost benefit analysis and feasibility analysis for the design and architecture of the new application.
• Involved in Requirement Scoping and analysing high priority requirement for implementation.
• Performed GAP analysis assessed As Is processes through user interviews, data collection and analysis, design and evaluation of To-Be process solutions.
• Involved in claim Transactions and Billing Transactions created flows for adequate matching of claims. Performed data mapping by matching the billing file and EDI claim file record claims received from Medicare and Medicaid agencies.
• Extensive validated 837 Healthcare Claims, 835 Healthcare Claims payment/ Remittance, 270/271 Eligibility request/Response, 834 Enrolment/Dis-enrolment to health plan for health claims.
• Created high-level Use Cases from Business Requirements and created UML diagrams like use case diagram and activity diagram m using MS Visio and UML 2.0 for various stakeholders.
• Well versed with HIPAA, Facets, STAR CHIP claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Involved in assisting QA Leads to develop Test plan and Test Case.
• Involved in UAT Developed UAT Test Plan and performed UAT tests along with the Business Users.
• Involved in Testing - developed Test Scripts using Test Director/Quality enter and coordinated with developers to quickly resolve the defects associated with them.
• Created 'Business Glossary' to facilitate efficient understanding of business process amongst other teams.
• Conducted JAD sessions during the various stages of upgrading the matching system and discuss the current system preference.
• Coordinated in designing an architecture that was flexible, scalable, performance-oriented, and provided a sustainable cost of ownership.
• Involved in ensuring that Business, Data Governance, and Integration team leads are deeply involved in critical design issues and decisions.
• Developed Requirements Tractability Matrix RTM using MS excel to trace each software design requirement to test case.
• Developed Complex SQL Scripts to help reverse engineering and mapping for various system applications.
• Worked closely with ETL and BI teams during project implementation and actively suggest ways and means to share and optimize work.