SUMMARY

• Over 8+ years of experience as Senior Business Analyst in the Healthcare Industry with expertise in Affordable Care Act (ACA), HL - 7, EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare and Medicaid.
• Solid understanding of Membership, Claims Processing, Billing, Benefit/ Eligibility, Authorization/ Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions (837, 834 and 820).
• Knowledge on Medicare, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, ICD-9, ICD-10, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.
• Experience with HIPAA EDI Transactions 837, 835, 820, 276, 277, 278 code sets testing in Health Insurance.
• 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.
• Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Having very strong domain knowledge of US health Insurance plans like: HMO, PPO, POS, EPO, Indemnity plans, Medicare & Medicaid.
• Proficient experience in working on FACETS environment and possess an extensive knowledge about various modules of FACETS system such as claims and membership.
• Knowledge and Experience on Membership Enrollment, Billing, Claims Payment Processing in relation to HIPAA, EDI, 5010 X12, ICD-10 codes 834, 837,835, and 270, 271 transactions.
• Experience with HIPAA/ Electronic Data Interchange (EDI) transaction sets- 270/271, 835/837, 276/277 transactions.
• Extensive knowledge on the various types of health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO, HMO.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277 and ICD-9 and ICD-10.
• Experienced in designing and reviewing Business Requirement Document (BRD), Functional Requirement Document (FRD), Use Case Specifications, Requirements Traceability Matrix and Testing Documents.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Customer service, membership management, provider management).
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Working experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS/RAPS).
• Facilitate and lead project meetings with various CMS stakeholders to elicit project information and resolve project issues.

PROFESSIONAL EXPERIENCE

Confidential - longbeach, CA

Senior Business Analyst

Responsibilities:

• Responsible for participating in the design sessions, reporting on project progress and identifying potential risks and issues.
• Involved in claim adjudication process of facets application
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)
• Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277, 837/835 transactions.
• Validated the following: 837 (HealthCare Claims or Encounters), 835 (HealthCare Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment / Dis-enrollment to a health plan)
• Was responsible for data mapping of HL7 messages into relational database.
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Defined and documented the vision and scope of the project.
• Experience in Revenue Cycle Management (RCM) for claims processing.
• Gathered requirements, developed Process Model and detailed Business Policies.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Involved in writing and implementation of the test plan, and various test cases for UAT.
• Worked with HIPAA compliant ANSI X12 834, 837, 276/277, 999 formats for both professional claims and institutional claims.
• Analyzed EDI transactions in XML and X12 responses.
• Prepared the Business Workflow using MS-Visio with input, output, Pre and Post conditions.
• Enhanced test cases and scripts by adding the required functionality as per the new business requirements.
• Participating in all phases of testing and working through document issues.
• Working the technical and development team to resolve identified issues in a timely manner.
• Reviewing documented training material for accuracy and assisting in end user training and support.
• Responsible for accomplishing business objectives by identifying and solving customer information and processing problems.
• Created XML configurations to accurately parse EDI, EDIFACT, CSV, and Excel data files into the Info Now Oracle database
• Applying triage, research, collaboration and technical knowledge to resolve transaction and processing issues with the use of supporting technology such as work flow management systems and case management software.

Confidential - Springfield, MA

Business Analyst

Responsibilities:

• Gathered business requirements through discussion with stake holders and SME’s.
• Performed Gap Analysis for HIPAA 5010.
• Involved in activities to make sure proper documentation and standards are being followed.
• Wrote Business Requirement Document after collecting requirements through conducting interviews, JAD Sessions and brain storming sessions.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions related to providers, payers, subscribers and other related entities.
• Worked on HIPAA Standard transactions: 270, 271, 276, 277, 278, 834, 835, 837, and 999 to identify key data set elements for designated record set. Interacted with Eligibility, Payments and Enrollment hence analyzing and documenting related business processes.
• Developed use case Designed process flow diagrams using MS-Visio and also Business Context Diagrams.
• Participated in software upgrades for claims work flow and EDI transactions (835,278) upgraded from Version 4010 to 5010
• Thorough knowledge of Eligibility and membership Affairs. Also, knowledge of HIPAA, X12, and HL7 standards and Medicaid provider best practices.
• Worked extensively on EDI transactions 837 and 835 Involved in writing test cases for different LOB’s for SIT, Parallel and UAT
• Worked on 270,271 Eligibility request and Eligibility response and on 276,277 Claim status request and response.
• Validated that the 270/271 generated is in accordance with the 5010-implementation guide.
• Ensured accurate enrollment data for health plan products across multiple systems.
• Assisted developers in trouble shooting and resolving EDI issues by collaborating with internal and external business partners to define business processes and information requirements by building on intermodal industry best practices and ANSI X12EDI standards.
• Constantly involved in review meetings and made sure testing is done based on the QA master plan and deadlines are met.
• Used FACETS to provide seamless transactions between the provider, members and the plan.
• Used Edifecs Transaction Management tool to verify that the batch and real-time files are generated correctly.
• Claim status Request and Response are generated according to the 5010 formats, validated the same.
• Was involved in working with the offshore testing team to co-ordinate Regression Testing.
• Monitored RTM to close the defects/cases as and when developers resolved the defects
• Communicated with developers and Business Analysts through all phases of testing to prioritize defect resolution.

Confidential - Columbus, OH

Business Analyst

Responsibilities:

• Assisted in identifying project scope, to conform to the regulatory compliance related to X12 837 I/P, 835, 834, 270, 271, etc.
• Responsible for soliciting and eliciting requirements for 4010-5010 conversions.
• Involved in building training material and planning material for 4010-5010.
• Defined communication plans and created a project budget for the transition.
• Carried out Risk Assessment, GAP analysis and Impact Analysis for the 4010-5010-conversion project.
• Involved in one-to-one interview sessions and JAD sessions with stakeholders, SME's and business owners to discuss the scope of the conversion.
• Produced for transaction sets 835 and 837 I/P a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy.
• Involved in up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 by conducting Impact Analysis and Risk Assessment and worked on the mitigation plan to avoid the risks.
• Worked as a liaison among stakeholders both business and IT side in order to elicit, analyze, communicate and validate requirements for changes to business processes.
• Involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Prepared UML diagrams Activity diagrams, Sequence Diagrams, Use case diagrams.
• Played a key role in project planning activities, User Acceptance testing, and implementation of the system enhancements and conversions.
• Involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions based on the findings.
• Conducted Business Process As-Is/To-Be sessions with various department directors and staff to ensure the Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program covered all identified new and changed processes.

Confidential - New-Port Beach, CA

Business Analyst

Responsibilities:

• Developed Use Cases using MS Visio, and a detailed project plan with emphasis on deliverables.
• Monitored Change Requests and documented requirements, integrating them with Use Cases.
• Developed and implemented Test Strategies using the Test Director.
• Followed the RUP methodology for the entire Software Development Cycles.
• Assisted the development team during the second and third iteration using the RUP model.
• Involved in project planning, coordination and implemented QA methodology.
• Developed the Requirements Traceability Matrix, prioritized and determined impact of all applications.
• Identified the all applications and interviewed the application owners to recommend the process improvements.
• Provided overall project management to multiple projects successfully completing them on-schedule and on-budget.
• Defect Tracking and Bug Reporting was performed using Test Director