SUMMARY

• Analytical, enthusiastic and innovative EDI Business System Analyst experienced in business analysis, data analysis deployment business processes and system solutions for Confidential and insurance domains.
• Comprehensive knowledge of Software Development Life Cycle (SDLC), having thorough understanding of its various methodologies like Waterfall, RUP, Agile or Scrum.
• Extensive knowledge of Software Development Life Cycle (SDLC), Object Oriented Analysis and Design (OOAD) using Unified Modeling Language (UML), Rational Unified Process (RUP), Waterfall model and Agile/Scrum model.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange), transaction syntax like ASC X12, Implementation and Knowledge of HIPAA code sets, ICD - 9, ICD-10 coding and HL7.
• Experience with Data Analysis and Data Mappings including HIPAA ANSI X12 4010A 270/271, 276/277, 834, 835, 837 for institutional, professional, and commercial claims, and up-gradation of ANSI 4010 to ANSI 5010.
• Prepared 5010 GAP documents involved with 837, 835, 834 and 278 transactions in collaboration with other team members.
• Extensive work with various Rational tools like RequisitePro- Requirement gathering/maintenance, Use Case document maintenance, Clear Case- version control and ClearQuest/TestDirector for bug tracking, Rational Rose for Use case diagrams, Sequence diagrams and activity diagrams.
• Followed the Agile methodology and extreme programming concepts of project development.
• Worked with various teams and data-architects to come up with processes in dev/qa/prod for extraction, transformation and loading the data into the datamarts.
• Efficient in MS Project/ MS Excel/ MS Word/ MS PowerPoint for planning/status reporting.
• Experienced in developing functional specifications through JAD sessions and user interviews.
• Actively involved in developing, executing and managing User Acceptance Testing (UAT).
• Experiences with Quality improvement organization.
• Facilitate communications and understanding of business/ functional requirements among different stakeholders and between stakeholders and technical team.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Hands on experience writing Test Plans and Test cases. Performed manual testing.
• Adept at reducing development costs and providing traceability of projects.
• Currently taking part in TOPDAWG (Technical Proposal and Writing) .

PROFESSIONAL EXPERIENCE

EDI Business Analyst

Confidential

Responsibilities:

• Provided day-to-day support on the VIP/ Escalation Team.
• Complete assigned casework for the various states for the tax reconciling on the 1095-A forms.
• Resolved various types of enrollment issues for policy start and end dates, APTC, Premium Amounts, Mailing address updates, and missing 1095A forms, Escalation cases, VIP Cases, High Priority CMS Cases
• Participated in testing and documentation of issues, case analysis documentation.
• Worked on special projects, included but not limited to highly time sensitive data research
• Helped create the CSOP for working 1095A cases by gathering details for all various types of cases worked by my team, wrote the document by including proper diagrams and illustrations to make it easy for anyone to follow, and also reviewed parts of the CSOP.
• Coordinated meetings amongst my team to go over the CSOP so that we could insure that we had the best guidelines to provide to current and new analysts.
• Work with the technical and development team to resolve identified issues in a timely manner.
• Review documented material for accuracy and assist in end user and support.
• While on the Dara Integration team, developed workbooks for 1095A cases by gathering data from all the required data sources for all analysts.
• Providing detailed for the VIP/Escalation Process to Team Leads and Team Members of ER&R.
• Worked closely with Payment Disputes to create mock cases and establish rules and documentation.
• Mentored new and current 1095A Case Analysts to support day to day activities.
• Currently taking part in TOPDAWG (Technical Proposal and Writing) .

Confidential

Sr EDI Business Analyst

Responsibilities:

• Involved in the meeting with Business Process Owners, SME (Subject Matter Experts) and store users for Requirement gathering for HIX project.
• Established a business Analysis methodology around the SDLC, helped to develop use cases, project plans and manage scope.
• Maintained Traceability Matrix in Excel.
• Participated in user meetings, gathered Business requirements & specifications for the enrollment, eligibility and claims in HIX system.
• Created Process Flow diagrams, Use case diagrams (UML) using MS-Visio
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams/State Chart Diagrams (UML).
• Created workflow diagrams to better demonstrate the processes adopted in the EDI group and accounting groups of the company.
• Worked in SDLC using Rational Requisite Pro
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Created new and modified existing reports using the Actuate Developer Workbench and integrated it with Siebel.
• Conducted the FRS reviews and walkthroughs with designers, developers and stakeholders.
• Prepared Screenshots and web layouts for the application
• Performed UAT based on Requirements Document

Confidential, Honolulu, HI

Sr. Business Analyst

Responsibilities:

• Conducted multiple JAD sessions between various organizations such as DHS, HHC, DCCA, and OIMT to elicit system requirements for HIX project.
• Requirements lead for Noticing, Languages, Change in Circumstances and Appeals.
• Interacted with the SME’s to gather information about the HIX project including health care enrollment, eligibility and health care claims processing and checked if the claims are processed correctly or not.
• Worked extensively on Gap analysis, Root Cause Analysis and Mapping of issues to requirements.
• Worked on many Change Requests, Parking Lot items, Action Items, Process Flow Diagrams, Pain Points, and Use Cases.
• Responsible for creating Dashboards, Reports, RTMs for CMS and other organizations.
• Functioned as JAMA and SharePoint administrator for logging of Requirements, Test Cases, Defect, Risks and Issues.
• Used Microsoft Project Online to create and monitor Project timeline for different functional areas.
• Created multiple workflows for daily follow up on Action Items, Risks, Issues and Decisions.
• Worked with Testing Lead to develop test cases / scenarios and mapped them to individual requirements.
• Worked with Policy analysts to ensure that system meets business requirements and policies.
• Utilized Waterfall and AGILE methodologies across various releases following the principles of SDLC.
• Worked as Defect Manager for triaging and prioritizing defects for resolution.
• Tested defect fixes in various Environments (Test/Stage) before approving the fix migration in Production.
• Worked with Issuers on Issuer rate validations and UAT prior to each release and on Issuer related defects.
• Worked on OneGate portal and Seibel CRM to validate and fix defects.
• Conducted regular meetings with SMEs and Contact Center Representative to follow up on updates on defects, discuss new defects and defect fixes for closure.
• Create User & manual for different users of JAMA software.

Confidential

Sr. Business System Analyst/EDI Analyst

Responsibilities:

• Worked on Claims,, Enrollment, Benefits and Data Validation
• Understood the business process that included Sales processes, Rating methodology, different Products, Group Renewals and Enrollment process in Facets.
• Provided hands-on expertise for implementation, configuration and on-going support of Facets to include analysis, system configuration, operational implementation, process documentation and testing for managed care clients.
• Analyzed the available artifacts such as BRDS, both functional and nonfunctional, Use cases, Data Flow Diagrams.
• Documented the scope of the project and building a project plan.
• Conducted daily meetings with the development team to communicate the requirements and make sure they were mapped according to the requirements document.
• Gathered requirements, Prepared Process Flows and Diagrams for the manual to automated conversion Project.
• Performed GAP analysis and create requirements traceability matrix of business rules, business and system process flows, user administration, and requirements.
• Identified the scenarios based on business requirement
• Created specifications documents and mapping documents
• Created and maintained quality system documents and records, e.g. flowcharts, procedures, forms, templates, spreadsheets, presentations
• Analyze the existing issue and prepare an estimation of the task based on the effort needed for this process
• Identify the Confidential code/logic responsible for issue and determine the root cause.
• Prepare high level change details to be implemented for issue correction - determine if the proposed logic is going to be new or updates to existing components.
• Identifying the component impacting the process change, determined whether the solution is generic across all the states or state specific.
• Based on the type of requirement, determined the appropriate requirement document template to address the solutions like prepare BRD in case of long term or effort intensive solution, Prepare Spring BRD in case of short term/ Emergency fix and if any changes to BRD(approved) then implement it as a PCR
• Worked closely with different Team and participate in many Testing activities.
• Involved in Test Planning, Test Schedule Management, Reporting, and Test Data gathering for Facets.
• Designed and Documented Test Procedures, Test Requirements, Test Scenarios and Test Cases for End-to-End functionality testing.
• Involved in testing Facets Member/Subscriber, Billing, Medical Plan, Dental Plan modules in Facets 5.01.
• Validated the creation of new application, plan change and dis-enrollments.
• Involved in testing Facets for Group Information, Enrolling Subscribers, adding members, Related Entities, Class/Plan definition, Premium Rate Tables and all.
• Reviewed and Analyzed, Business, System and Technical requirements of the application.
• Involved in developing and executing Test Plan, Test Scripts and Test Cases for Facets 5.01 based on the requirements.
• Coordinated in the development and testing of UNIX application to store all X12 incoming and outgoing EDI transactions to Oracle database for audit purpose.
• For planning purposes, generated EDI transactions daily and monthly reports from EDI Gateway Real time system for business.
• Executed vast amount of SQL queries to test the integrity of the database using TOAD.
• Used Quality Center as test management tool for defect tracking and test case execution.
• Used Quality Center 10.0 for defect tracking and maintained the trailing history of the bugs.
• Prepared Traceability matrix, bug matrices, weekly and daily status reports and sent to management.
• Interacted with Development Team to fix the defects raised during the testing period.

Confidential, Tampa, FL

EDI Business Systems Analyst

Responsibilities:

• Worked as a team member of a group of analysts in communicating with business and IT to analyze and document application system.
• Gathered, identified and documented business and test requirements.
• Updated the existing business requirement documents as a part of change management process to include and/or update new requirements.
• Based on the project change management documents gathered, analyzed and documented technical solutions for the BRDs.
• Worked closely with developers to understand and document technical logic for the medical claim adjudication systems.
• Documented the technical solutions of the business requirements as a part of Technical Requirement Document (TRD) for medical claim adjudication system.
• Worked on conversion claims, reporting, Baking and payment processing once the claims were processed.
• Experience in EDI testing process including validation of inbound and outbound X12 files, pharmacy claims, various loops and segments, claims in diamond
• Involved in testing method for data exchange for Outbound Eligibility 834 File, Pre- Transmitted from HPS to AMM and File and Medical Case Management Transmitted from AMM to HPS.
• Worked on Validated Eligibility load from TAS (Mainframe) to spyglass once the cases were issued on CSR.
• Created claims, members, groups using Diamond
• Involved in developing Test Plan and created Test Cases as per the business requirements in Quality center for Confidential Registration Module
• Extensively involved in creating test data and executing the test cases for the UNIX batch jobs.
• Worked on Validated fill file (enrollment data).
• Worked on Validated member and their attributed on CSR.
• Work on validating Broker Portal which included validating Quote Generation, Quote Output, Broker Links and Access and Discount Buckets per Producer roles as defined in requirements
• Analyzed BRDs, SRSs to ensure 100% Requirements coverage in execution of Test cases.
• Validated 837 (Institutional, Professional) 835, and 834 HIPAA Transaction sets and X12 messages
• Discuss enhancements and modifications with the Project Team
• Use team track to track, analyze, and log the defects to report them to developers.
• Compared the parser generated XML claim data with slicer generated CU files to validate the claim match.
• Reported the project status and activities to the Supervisor on weekly basis.
• Involved in preparing the Test cases, Test data in Team track for Report Repository upgrade.
• Work with the Developers, Infrastructure teams to resolve the issues.
• Have written and executed SQL queries to ensure that member plan attributes and CIM numbers are associated with members under specific carrier appropriately and no Duplicate or Improper allocation of member attributes and CIM numbers are done.
• Extensively used Agile Methodology and Adhoc testing for the applications.
• Tracked and managed problems during UAT.

Confidential, Trenton, New Jersey

Business Analyst

Responsibilities:

• Facilitated Gap Analysis:
• Coordinated with NJ state subject matter experts, gathered and documented business requirements BRD for communications
• Maintained effective working relationships with NJ state staff by responding to needs & exhibiting a sense of urgency when needed
• Liaised with business and functional owners during risk engineering and high-level review sessions to derive and execute action plans to meeting deadlines
• Partnered with business users and acted as a liaison between business and technical
• Defined requirements using JAD sessions for Non MAGI Medicaid, TANF and SNAP
• Collaborated with developers and subject matter experts
• Documented requirements, business process flows, use cases and workflow functional deliverable documents

Confidential, Chattanooga, TN

EDI Business 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.
• Design and development of inbound and outbound maps.
• Worked on EDI transactions like 270/271, 276/277, 835/837, 834, 820
• 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 Facets Implementation.
• Prepared Use cases, Sequential Diagrams with detailed screen layouts with regards to various types of Confidential actions.
• Extensive Analysis of HIPAA rules to in Confidential 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, 834, 820, 270/271, 276/277 transactions.
• Implemented Rational Unified Process (RUP) in terms of disciplines and phases, each consisting of one or more iterations. With the iterative approach, the emphasis of each workflow varies throughout the lifecycle. The iterative approach helps address risk early and continuously, through demonstrable progress and frequent executable releases.
• Identified High-Level Requirements for developing and documenting detailed business requirements using Rational