- More than 6 years of professional experience as a Business Analyst with broad exposure and experience in the entire system development lifecycle.
- Profound understanding of insurance policies like HMO and PPO and proven experience with EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim status), 834(Benefit enrollment), 837(Health care claim).
- Excellent working knowledge of SQL Server Reporting Services (SSRS), SQL Server Integration Services (SSIS), SQL Server Analysis Services (SSAS).
- Good working knowledge of Claims processing, Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction Set EDI X12 837, 270/271, 276/277, 278, 834, 835
- In - depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
- Strong experience in Requirements Modelling by creating Business Process Model Notation ( BPMN), Use-Case models, User Stories, AS-IS, TO-BE process models, Entity Relationship Diagrams and Activity Diagrams.
- Excellent experience with developing Quality of Service ( QoS) requirements for various applications developed
- Extensive hands-on and HealthCare management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support the Medicaid Management Information System (MMIS) as well as day-to-day business operations.
- Experience with Microsoft BI tools (Power Pivot, Performance Point, Excel Services, Report Builder, Reporting Services etc.) and/or other reporting tools like Tableau
- Experience in solution assessment, validation and applying critical thinking for problem solving approach.
- Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA(Patient Protection and Affordable Care Act), FHIR, Compliance issues, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
- Extensive experience in Functional, Integration, Regression, User Acceptance (UAT), System, Load and Black Box Testing.
- Expert in application/system development life-cycles; concurrent development strategies, process streamlining, iteration modeling, rapid application development (RAD/RUP/UML), and legacy/waterfall methodologies.
Business Modeling: UML modeling using Rational Rose Enterprise Suite, UML CASE Tools, MS Visio
Requirements Management: DOORS, Rational RequisitePro, Visio
Project Management: MS Office Suite & MS Project
Defect Management: ClearQuest, JIRA, QC, ALM
Methodologies/Frameworks: Rational Unified Process (RUP), Agile, Waterfall
Database Systems/Query Languages: Oracle database, MS Access, SQL, PL/SQL, SQL Developer, TOAD
Operating System: Unix, Linux, AIX, Solaris, MS Windows, Mainframe z/OS
Confidential, Lansing MI
MMIS Business Analyst
- Analyzed plan requirements and then contributed further defining the plan requirements with their Project Manager and observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements.
- Responsible for designing, developing, and deploying Business Analytics Dashboards using Microsoft BI technologies including SQL Server, Power BI, Excel etc.
- Generated reports of transactions using sql server reporting services (SSRS ) and SQL Server Integration Services (SSIS) .
- Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan).
- Assisted SharePoint Administrator with upgrade and transition to SharePoint 2016 from SharePoint 2013 and quality of service (QoS) requirement.
- Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
- Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS. Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
- Ensured that Medicare Advantage membership enrollment was in sync by reconciling CMS enrollment records and Horizon enrollment records.
- Created detailed Use cases, BPMN flows, Functional Specifications, UML diagrams to remove ambiguity of the requirements communicated by clients or SMEs.
- Provided technical support to 268 clients which included software updates, troubleshooting software, hardware, EDI, HL7, SQL and Windows related issues
- Prepared vendor selection criteria sheet based on HL7 conditions, researched strengths and weaknesses of tools, competitor website analyses etc.
- Worked with Cognos and micro strategy reporting systems to extract the data for analysis using filters based on the analysis.
- Facilitated, monitored and leaded the Scrum process from initiation through delivery in SAFe agile methodologies
- Internal review of user stories with management for scenarios/test data/screen shots prior demo.
- Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications.
- Used ETL for data flow from different source files like XML, Excel, Tables, and Views to other databases and files with proper mapping.
- Generated monthly and quarterly reports as bar charts for the management using different techniques like data filtering, adding interactivity, deploying reports to report server using SSRS
- Created Business Insight Dashboards and Business Insight Advanced prototypes for the user to understand the new Cognos features and functionalities.
- W orked with SSIS, for ETL process ensuring proper implementation of Event Handlers, Loggings, Checkpoints, Transactions and package configurations.
- Documented changes needed to vendor system to convert legacy internal Billing data into the vendor system and checking quality of service (QoS) and TFS tool.
- Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins.
- Coordinates with Data Warehouse Architects to create and support Business Intelligence environment. Identifies and works with appropriate staff to resolve technical issues
- Conducted Data analysis using SQL on the backend databases for producing mapping documentation and transformation rules for developers.
Confidential, Worcester, MA
Business Analyst/EDI Analyst
- Maintained and kept track of stakeholder's requests for enhancements and changes using Rational Clear Quest.
- Used Microsoft Team Foundation Server ( TFS) to manage the team's software development lifecycle
- Created ETL metadata reports using SSRS, reports include like execution times for the SSIS packages, Failure reports with error description.
- Verified Member Enrollment and Benefits with the TriZetto MMS process of Facets Group, Subgroup, Class/Plan, Product and Subscriber/Family applications.
- Developed and implemented policies and procedures which includes process flows, guide sheet for all important responsibilities as part of development of Medicare Operations Manual.
- Involved in vendor selection, defining SLA, QoS, info-security, ODC operational governance. Built excellent cross functional matrix teams for seamless delivery management.
- Built effective queries for high-performance reporting and rendered them to html, xml, pdf and excel formats using reporting services (SSRS ).
- C reated complex SSIS and DTS packages for ETL purposes. Implemented complicated transformations in the development of SSIS packages.
- Escalated Cognos BI related issues to Cognos Alliance support and got them resolved.
- Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
- Responsible for creating the staging tables and source to target mapping documents for the ETL process.
- Gathered requirements and use case scenarios for all HIPAA X12 transactions to be upgraded to a new platform for compliance, validation and routing that included process flows
- Created TO-BE process model of the new application being developed by using BPMN diagrams and Use-Cases
- Performed Data Analysis and Data validation by writing complex SQL queries using TOAD against the ORACLE database.
- Reviewed and understood CMS regulations, data files and requirements that support Medicare D premium billing processes.
- Create complex JIRA workflows including project workflows, field configurations, screen schemes, permission schemes and notification schemes.
- Documented all system changes and request for user access using Change Management Forms in the SharePoint document library
- Verified Business requirements, Data Quality issues using Ad hoc excel Reports and developed cognos Reports.
- Developed a strategy for developing and implementing new EDI (HL7 and x12) interfaces and converting historical clinical and data.
- Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
- Formulated system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes such as HIPAA/ EDI formats and accredited standards.
- Educated providers on the Centers for Medicare & Medicaid Services Guidelines for claims, Medicare Part B benefits and all Medicare Part B services.
- Wrote detailed specifications for various reports generated using Cognos.
- Communicated with vendors and provider offices regarding HL7 file specifications and testing information and answering initial questions.
- Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
- Implemented and maintained all EDI payer files for private, Medicaid and Medicare insurance plans
- Provided details regarding Medicare Secondary Payer (MSP), Coordination of Benefits (COB) and Medicare not eligible services due to Member’s Medicare Replacement Plan Enrollment.
- 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
- Created Data profiling stored procedures using dynamic SQL as well as generating complex scripts to schedule various maintenance tasks
- Reviewed Daily Transaction Reply Reports (DTRR) and the Monthly Membership Reports (MMR) while abiding by Federal Centers for Medicare and Medicaid Services guidance (CMS).
- Involved in Planning & Product Backlog Grooming User Stories with Business Analyst and Team members.
- Served as a Relationship between internal and external business community Claims, Billing, Membership, Customer service, Healthcare Management and the project team.
- Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
- Worked within the areas of process improvement and enhancements of Billing/ Payment systems for Medicare Part D functional area.
- Worked successfully on parallel testing which involves comparison of the state legacy system data with new Health Enterprise (MMIS) system data and analyze the accuracy of the claims processed through new Health Enterprise (HE) system.
- 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.
- Organized and facilitated Agile and Scrum meetings, which included Sprint Planning, Daily Scrums or Stand-ups, Sprint Check-In, Sprint Review & Retrospective.
- Work on production issues related to claims pricing, provider and claims adjudication of Nebrarska MMIS.
- Created, tested, and demoed various SharePoint sites including creating document libraries, lists, links to other web sites and SharePoint sites and web parts and their content using SharePoint Served as a liaison between mortgage specialists and the project team.
- 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
- Developed QoS non-functional requirements for the enhancements to the website
- Analyzed System Impact including MMIS Tables, Windows, Reports and Interfaces to external entities.
- Analyzed various inbound and outbound interfaces to determine the impact of HIPAA 5010 and NPI implementation.
- Quoted benefits and claim status on Legacy contracts prior to their conversion to the Facets system.
- Assisted the Central Migration team answer benefits and claim status questions on contracts converted to the Facets system.
- Worked on improvement of Claims Reimbursement User Interface for a better experience and incorporate changes as per HIPAA guidelines using the gap analysis.
- Analyzed HIPAA 5010 impact on external Data Warehouse and data warehouse extract process and mapping of MMIS database and data warehouse.
- Utilized SOAP techniques to provide basic messaging framework for web services
- Analyzed various resource files being used to generate the report and documented data mapping and data source interface documents to assist the development team.
- Writing Epics and user stories, managing sprints and backlog grooming, and tracking project progress in JIRA.
- Analyzing User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
- Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
Confidential, Middletown, NY
- Designed SSIS Packages to transfer data between servers, load data into database on SQL Server environment and deploy the data.
- Analysis of Business requirements & Design Specification Document to determine the functionality of the ETL Processes.
- Responsible for the development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837P and 5010.
- Used HL7 guidelines and dictionary for defining business rules associated with pre-defined workflows according to business requirements.
- Conducted interviews with key stakeholders to analyze existing data and gather requirements.
- Worked on the Patient Management System (integrated version of Patient Information System with EMR/EHR)) is intended to
- Used HIPAA guidelines and regulations to keep track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.
- 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.
- Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
- Created Custom Entities, Custom attributes for individual business units in MS Dynamics CRM, according to their business process Customized Workflows and Plugin for
- Analyzed requirements to define the process flow in BPMN, Use cases and activity diagrams in UML
- Adding scenarios, test data and screen shots used for testing to Test Ready User Stories in JIRA.
- Involved in Task and resource allocation; schedule, status, and issue reporting; identification of and distribution of requirements, high, and low level design; development of and verification of SQL queries for reports, coordination of development, and execution and coordination of integration, and testing, for an Oracle based business
- Created UML-based feasibility studies and Use Case Models to communicate those ideas to the developers.
- 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.
- Involved several working sessions and much 'offline' research/documentation with the key stakeholders and SME's from the Pharmacy department.
- Contacted insurance companies for explanation regarding no payment or rejection
- Facilitate and deliver continuing education support on the HDR Healthcare Data Repository and Improve understanding of clinical applications and use scenarios for respiratory products in targeted markets
- Trained the team on JIRA tool for Agile/ Scrum Methodologies and utilized JIRA to develop and track agile, stories and tasks.
- Followed the UML based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, and Sequence Diagrams.
- Used Rest services for communication of XML into web services and validated the response XML by defining the transformation logic required to transform the response XML into parsed JSON format.
- Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle