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Healthcare Business Analyst Resume

Abington, PA

SUMMARY

  • 8+ years of Experience as Business Analyst in Healthcare include understanding of Business Requirement Gathering, Business Analysis, Joint Application.
  • Extensive experience in Gathering Requirements, Scoping Requirement and creating Business Requirement Documents, User Requirement Specifications, Functional Requirement Specifications, System Requirement Specification, Test Plan, analyzing and Creating Use Cases, Use Case Diagrams, Activity diagrams, System Workflow Diagrams, Data Flow Diagrams, Business Flow Diagrams.
  • Expert in documenting project plan, Business Requirements Document (BRD), Test Plans, Use Case Specifications, Functional Specifications (FSD) and Systems Requirements Specification (SRS).
  • Expert in UML methodology to create UML Diagrams including Use Cases Diagrams, Activity Diagrams, Sequence Diagrams, Data Flow Diagrams (DFDs), ER Diagrams using Rational Rose and MS Visio and thus defining the Business Process Model and Data Process Model
  • Extensive experience as Business Analyst in the Healthcare Industry with expertise in EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare and Medicaid.
  • Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
  • Gained extensive experience in designing/modifying the CICS screens for various areas such as Enrolment, Billing, Provider Record and Reimbursement Status in MMIS. Enrolment, Billing, Provider Record and Reimbursement Status in MMIS.
  • Adequate knowledge in Health Administration - Claim’s processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Medicare, Medicaid, CDHP (consumer driven health plans).
  • 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 835).
  • Worked with EHR (Electronic health record) and EMR (electronic medical record) team for data requirement.
  • Customizes and runs training program for physicians on EMR product optimization especially with regards to patient safety, physician efficiency, EMR incentive programs and federal and state regulatory requirements.
  • Knowledge of managed Claims management process, Knowledge of Medicaid, and Medicare Services. CMS, Health Assessment Systems, HIPAA, EDI, Electronic Health Records, Electronic Medical Records (EMR).
  • Well versed with Medicaid Management Information Systems (MMIS), National Provider Identification (NPI) and familiar with Patient Protection and Affordable Care Act (PPACA), Health benefit Exchange.
  • 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.
  • Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
  • Extensive knowledge about the various types of health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO (Preferred provider organization), HMO (Health maintenance organization), Medical Management Information Systems MMIS
  • Experienced working in Medicare and Medicaid projects.
  • Proficient in using UML for Business Process Modelling, Use Cases, Activity Diagrams, Sequence Diagrams, Data Flow Diagrams, Collaboration Diagrams, Class Diagrams, Wireframe, Prototypes and documenting them using Microsoft Visio.
  • Experience in Medicaid Management Information System (MMIS) and expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
  • Experience in working with various functional areas of MMIS like Claims Edits & Audits, Claims Pricing, Claims Payment & Financial and Claims Front End.
  • Extensive experience in analyzing and resolving defects related to various MMIS functional areas and experience in implementation of CPT codes changes in the current claim processing modules in MMIS.
  • Experience in analysis of as-is business process and to-be design processes (Gap analysis).
  • 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.
  • GRC (Governance, Risk and Compliance) duties - Work with Audit, IT, Governance, Risk, & Compliance, and the Lines of Business to standardize provisioning and recertification processes to ensure proper Data Security Administration practices.
  • Experience and complete understanding of QA Life Cycle, which includes Designing, Developing, Execution and Documentation of the Test Cases, Automated Test Scripts and Test Plans.
  • Excellent skills in Business Analysis, Data Analysis, Requirement Analysis, Business Modelling and Use Case Development using UML methodology.
  • Experience in database modelling and development of Entity Relationship Diagrams (ERD)
  • Highly experienced on implementing HIPAA standards and good Knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare).
  • Experienced in determining membership eligibility, billing experience within life and disability in health plans with through understanding of CPD coding, CMS -1500 claim forms and reimbursement forms.
  • Experience in writing Medicaid and Medicare requirements as per the Centres for Medicare and Medicaid services (CMS) guidelines.
  • Strong Experience in Claims, Claims Intake Process, Claims Adjudication Process and Claims scrubbing in HMO, PPO, POS, Medicaid, and Medicare.
  • Good experience in developing Test Plans, Test Strategies, Test Scenarios, Test cases by reviewing Business and Software Requirement specifications and creating Gap Analysis for test purpose.

PROFESSIONAL EXPERIENCE

Confidential

Healthcare Business Analyst

Responsibilities:

  • Responsible for architecting integrated HIPAA, Medicare solutions, Facets Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
  • Gathered information from different data warehouse systems and loaded into warehouse using Fast Load, Fast Export, Xml import, Multi Load, BTEQ, Teradata parallel transporter (TPT) and UNIX shell scripts.
  • Worked on analyzing business requirement at all stages of Software development of life cycle SDLC.
  • Created approach to standardize Excel Reporting using SQL in the Management Dashboard.
  • Wrote transformations for data conversions into required form based on the client requirement using Teradata ETL processes.
  • Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology. Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business 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.
  • Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
  • Manage and analyze data communication channel to ensure compliance security requirements in accordance with ISO, HIPAA, and PCI guidelines. Coordinated with Project Managers to resolve risk issues and ensure compliance of Security System related to the HIPAA.
  • Worked with PPI Teradata tables and was involved in Teradata specific SQL fine-tuning to increase performance of the overall ETL process.
  • Involved in requirement gathering phase (Provider, Claim components and HIPAA). Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures.
  • Led the development of methods for key GRC process, along with the identification of the most feasible GRC solution and implementation process for the enterprise.
  • Experienced in planning, administrating, developing and delivering automated GRC solutions using various GRC tools (RSA Archer eGRC Framework, Metric Stream)
  • Manage and lead day-to-day operations of system upgrade to comply with new federal reporting requirements and security protocols including HIPAA.
  • Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
  • Involved in all steps of Software Development Life Cycle (SDLC).
  • Develop mock-up Wireframes using HTML, JavaScript, and PHP for clients JAD sessions.
  • Utilized knowledge of SQL Programming to author over 20 Queries in the Management Dashboard.
  • Skilled in gathering business and application requirements, Business Processes, identifying risks, impact analysis, UML modelling, and Sequence and Activity Diagrams using Rational Rose and Microsoft Visio in Clinical and Health Information Management (HIM) processes.
  • Used BTEQ and SQL Assistant (Query man) front-end tools to issue SQL commands matching the business requirements to Teradata RDBMS.
  • Sound knowledge of Patient Protection and Affordable Care Act (PPACA), HIX (Health Insurance Exchange), SOPs (Standard operating Procedures) and forms, GMP's terms and Practices.
  • Coordinated and conducted meetings with State Medicaid staff, programmers, and project managers to discuss and develop technical and business solutions for all tasks where problems and disagreements arise.
  • Excellent working knowledge in Project Life Cycle and clear understanding of Project Management.
  • 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 Enrolment hence analysing and documenting related business processes.
  • Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements.
  • Maintained Requirement Traceability Matrix (RTM) and Utilized Clear Quest for change requests and defect tracking.
  • Conducted successful projects with the help of teams to achieve deadlines timely and proficiently.
  • Experienced in developing GUI, working together with developers and end-users to perfect the end-user’s requirements.
  • Organized, goal-oriented, self-starter, and ability to master new technologies manage multiple tasks while following through from start to completion.
  • Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
  • Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.

Confidential, Abington, PA

Healthcare Business Analyst

Responsibilities:

  • Gathered Business Requirements and managed them using Requisite Pro.
  • Interacted with the Users, Designers and Developers, SMEs, Project Manager to get a better understanding of the Business Processes.
  • Prepared Business Requirement Documents (BRD) based on the gathered requirements and broke it down to SRS in consultation with the technical team.
  • Performed UAT and regression testing on EDI 835 and 837 X12 formats in Facets.
  • Analyze, design, document, test, coordinate HL7 implementations and provided support to team for HL7 interfaces between Health Information Systems (HIS) and ancillary application systems.
  • Conducted the SRS reviews and walkthroughs with designers, developers, and stakeholders.
  • Assisted Project Manager in Project Management Documentation and got MS Project experience.
  • Analyzed business needs and developed use-cases &use case diagrams using Rational Rose and complied them into System Requirement Specification (SRS) document.
  • Documented Claims processing lifecycle and got good exposure of X12 837, 270 transactions for HIPAA 4010& 5010.
  • EDI file testing for checking the HIPAA 4010 compliance of the inbound 837 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 Enrolment hence analysing and documenting related business processes.
  • Worked with Java code/applications.
  • 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.
  • Created and maintained source-to-target Data Mapping and Data conversion spread sheet.
  • Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
  • Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
  • Elicited and documented requirements and proposed solutions through interviews, document analysis, requirements workshops, business process descriptions, scenarios, business analysis, task and workflow analysis.
  • Gathering requirements and preparing functional documents for Facets.
  • Prepare statistical and medical quality performance reports.
  • Developed business process models in conjunction with other supporting documentation and artifacts.
  • Developed, documented, and reported data quality goals and standards.
  • Analyzed requirements and design/tech-specs for testability.
  • Involved throughout the Software Development Life Cycle (Agile- Scrum), including Sprint Planning Meeting(s), Sprint Review Meeting(s) and Backlog Refinement Meeting(s).
  • Analyze application enhancements for compatibility with other application components, interfaces, and impact to Current State business workflow.
  • As a Governance, Risk and Compliance (GRC) Analyst shall providing support for revising internal security policies and standards, participating in risk assessments and audits with stakeholders
  • Strong Experience in GRC Tools, GRC Consulting Risk Compliance Assurance Technology, GRC Technology, GRC Process.
  • Utilized Inner join and Outer Join SQL queries to analyze the integrity of data.
  • Assisted the QA team in writing test cases and test scripts for testing the migration of EDI 4010 to 5010 and the processing of member Enrolment and benefits, batch jobs corresponding to the claims (837) and real time transactions like 270/271/276/277.
  • Understood and assessed the current EDI Transactions used and the existing Pharmacy Transactions from an NCPDP perspective.
  • Created data mappings to transform the data according to business rules.
  • Re-engineering the capturing of transactions with legacy systems, Eligibility Transaction 270, 837 Claim Status Request and Response 276.
  • Prepared Test Strategy, Test Plan, test report and Requirement Traceability Matrix using HP QC.
  • Maintained a change request log, conducted impact analysis when a request for change (RFC) was raised, escalated the results to Change Control Board (CCB) and updated documents on to SharePoint.
  • Met with the business owners to analyze showstoppers or critical issues that needs to be fixed before go live.
  • Validated member's benefits against the benefits matrix.
  • Maintained requirement traceability matrix on daily basis and participating in daily defect triage and status meeting.
  • Planned and documented procedures for data processing and prepared data flow diagrams for the application.
  • Worked with systems area to translate business needs into system requirements.
  • Worked with QA team and make sure the test cases and test process guarantee accountability to business and systems requirements.
  • Involved in the testing phase right from the Unit testing to the User Acceptance testing.

Confidential, Bethesda, MD

Healthcare Business Analyst

Responsibilities:

  • Prepared the Functional Specification Document (FSD) and Software Requirement Specifications (SRS) as per SEI-CMM standards.
  • Conducted the JAD Sessions with stakeholders and developers to have a clear picture of a project.
  • Conducted interviews with key stakeholders to analyse existing data and gather requirements.
  • Used UML to create use case diagrams, sequence diagrams and activity diagrams.
  • Developed flowchart and process diagram using MS Visio.
  • Wrote SQL scripts for creating performance evaluation reports.
  • Strong knowledge of HIPAA rules to store the transactions.
  • Monitored all the HIPAA transactions through the gateway.
  • Prepared Test Cases based on business requirements and business rules for HIPPA EDI Transaction 834, 276/277, 270/271, 837/835.
  • Validate the date from EDI transaction.
  • Analysed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers, and other related entities.
  • Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
  • Performed Backend testing by using PL/SQL queries to test the integrity of the application was in regular contact with Business partners on the status of issues, action plans and timeframe for resolution throughout the development cycle.
  • 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.
  • Identified bugs during the test phase and reported them using HP Quality Center.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
  • Knowledgeable about preparing RTM documents.
  • Maintained Traceability Matrix throughout the project.
  • Developed Test Cases and Test Plans based on requirements and did manual testing of the functionality of the application to ensure that the application can handle a lot of data.
  • Conduct Presentations periodically to the management and end users during various phases of Software Development Life Cycle (SDLC).
  • Conducted UAT, documented and reported user feedbacks to management team, and developed training materials for different end users and assisted in users training for the new system.

Confidential, Hartford, CT

Healthcare Business Analyst

Responsibilities:

  • Implemented the SDLC for the developing life cycle and followed the standards process in the application.
  • Prepared the Functional Specification Document (FSD) and Software Requirement on specific standard.
  • Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
  • Translated business requirements into functional requirements and approaches for developers.
  • 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.
  • Provided assistance in building EDI’s 270, 271, 276, 277, 470, 835, 837 and 834 transactions.
  • Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
  • Analysed data architecture, documented and delivered data mapping, performed risk analysis.
  • Frequently communicated with developers to resolve technical issues.
  • Workflow documentation and comprehensive training to the healthcare clients.
  • Analysed corporate healthcare business processes to develop customized solutions. performed unit testing and system testing on Confidential claims.
  • Worked on enhancement & rescoping of system requirements suited to operate on the new platform.
  • 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.
  • Effectively reduced wide gaps to generate claims as per the requirements of the new operating system.
  • Interacted with healthcare clients to gather requirements, objectives, and input and output requirements.
  • Developed test cases and scripts for front end testing.
  • Performed execution of test cases manually to verify expected results.
  • Ensured the accuracy and consistency of the data during the data loading process.
  • Developed Flowchart and process diagram using Microsoft Visio.
  • As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.
  • 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.

Confidential

Healthcare Business Analyst

Responsibilities:

  • Gathering and documenting the requirements in Requisite Pro those are critical to the business mission and using those requirements to design application software using a Use Case approach.
  • Created EDI documents for EDI maps to generate requirement documents and Project Charter, and logical design documents for EDI transactions and code sets.
  • Worked on FACET to terminate or reinstate health coverage for the subscriber.
  • Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
  • Documented requirement for HIPAA, EDI transaction 837 and for Medicare Part A, Part B, Part C and Part D.
  • 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.
  • Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record.
  • Analysed HIPAA 5010 related to 837,835, 270, and 271. Transactions and performed gap analysis between the 4010.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
  • Involved in Facets Configuration to make sure all information will be sent without any error.
  • Interacted with the “Users” by interviewing them, by preparing questionnaire and getting feedback.
  • Attending Client Meetings Project Steering Committee Meetings and Project Management Committee Meetings.
  • Ensured that all Lines of Business specifications were consistent in form and function to the Diamond Base 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.
  • Preparing BRD, Business Cases, and presentation to the clients, Business Re-engineering proposals.
  • Involved in TriZetto Facets System implementation, Electronic Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 835 and proprietary format files and Reports development.
  • Worked in RUP using Rational Requisite Pro. Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
  • Developed a vision plan that defined the primary goals and objectives of the project. Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagrams so that developers and other stake holders can understand the business process by using UML.
  • Data mapping, logical data modelling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
  • Engaged in analysing requirements, identifying various individual logical components, expressing the system design through UML diagrams.
  • Facilitated and managed Joint Application Development (JAD) sessions with committee of SMEs (Subject Matter Experts) from various business areas.
  • Analysed and Documented Business Requirement Document (BRD), Functional Specification Documentation, and System Requirement Documentation, using UML methodologies.
  • Performed Functional design/Data Modelling/user interface design of a financial services Client master database/data warehouse.
  • Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.

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