SUMMARY

• Qualified professional with almost 8 years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Expertise in Claims, Subscriber/Member, Plan/Product, Provider, Commissions and Billing Modules of Facets.
• Extensive experience in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from a Operational Data Store to a Enterprise Data Warehouse
• Identified functional Test Cases, Documented, and Executed test script in Facets system.
• Strong visual modeling and business process modeling skills using Rational Unified Process (RUP) and Agile Unified Process (AUP) with tools like Rational Rose, MS Visio, and well experienced in developing Use Case Models, Entity Relationship Diagrams (ERD), Data Flow Diagrams (DFD), Activity Diagrams, Sequence Diagrams and UML CASE tools
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Highly proficient in working with users to gather requirements, analyze them and subsequently use the Rational project and design tools to model the requirements.
• Good Knowledge of HIPAA Compliance Lifecycle, HIPAA Insurance Regulations and Claims Processing.
• Experienced in SQL Server Reporting Service (SSRS), Executing Queries and Running Store Procedures.
• Solid experience with SQL Server and T - SQL in constructing triggers, tables, user functions, views, indexes, user profiles, relational database models, data dictionaries, and data integrity
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Documented High Level Design (HLD) and Low Level Design (LLD) Documents to define the system rules by creating Use cases, interface designs etc.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Leads use case review sessions with business owner, technical lead and developers.
• Responsible for creating different sessions and workflows to load the data to Data Warehouse using Informatica Workflow Manager.
• Experience with TriZetto Facets 4.21/4.31 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications
• Gathered and documented Non-functional requirements.
• Knowledge of healthcare standard Health Level Seven (HL7).
• Performed UAT and exposure to User Certification Testing (UCT) and Operational Readiness Testing (ORT)
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Experience with HIPAA compliance and CFR Part II electronic exchange guidelines.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.

TECHNICAL SKILLS

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite(Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Mainframe: COBOL, DB2, JCL, CICS, MVS

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

PROFESSIONAL EXPERIENCE

Confidential, Worchester, MA

Sr. Business Analyst

Responsibilities:

• Worked with Facets Applications Facets TriZetto Eligibility/Enrollment transactions, Managed Care and MMIS Health Insurance Claims Processing system.
• Created EDI documents for EDI maps to generate requirement documents and Project Charter, and logical design documents for EDI transactions and code sets.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Responsible for creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes
• Ensured that X12 transactions (837, 835, 277C, 997, 999) could be carried out as per the EDI standards during any of the system changes as well as system upgrades.
• Created and implement Maps for HIPAA standard 837I/P, 834, 835, 820, 270, 271, 999 etc Examine and correct any errors or exceptions in file content.
• Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well.
• Mapped provider data from source to target Facets 4.31 data layout for the claims and benefit configuration.
• Used Facets 4.31 to receive, store and send HIPAA-standard transactions (835, 837, 270, 271, 276, 277) and to administer HIPAA privacy rights.
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Modified EDI XML/x12 837 & 820 files and EDI Test data file for each Test Scenarios for the creation of Letter, Email and Live Dialogue Format Contract letter templates.
• Created test scenarios for 837P, 837 I & D, 835, 834, 820, 270/271 and 278 transactions.
• Involved in GAP analysis of 270/271,837 P & I and 834 transactions from EDI X12 4010 to EDI X12 5010.
• Monitored and validated daily claims processing of EDI 837 and 820 EDI x12 files to Providers and trading partners; ensuring that the acknowledgements are sent to the Providers.
• Performed transmission troubleshooting problems for the following ANSI X12N formatted EDI transaction types: 837P, 837I, 837D, 834, 270, 271, 276, 820, 835, NCPDP Encounters
• 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.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Created EDI files for test cases and verified those files, debugged the errors and corrected them according to the addenda for respective HIPAA implementations
• Worked also as a Subject Matter expert and analyzed all aspects of the software development life cycle including business requirement analysis, application Logical & Physical design, development milestone determination, code implementation and all various levels of testing (unit, integration & UAT) along with end user training for ICD-9, 10 applications.
• Facilitated and managed Joint Application Development (JAD) sessions with committee of SMEs (Subject Matter Experts) from various business areas.
• Performed backend testing using SQL queries and analyzed the server performance on UNIX OS.
• Loading staging tables on Teradata and further loading target tables on SQL server via DTS transformation Package.
• Utilized PL/SQL (stored procedures, functions, packages and triggers) and SQL (queries) programming to create business logic.
• Performed UAT Testing based on Requirements Document and prepared the Test Cases using Quality Center.

Environment: Java, AGILE, RUP, MS Office, DB2, UAT testing, Linux, HTML, MS Project 2004, BI, Facets 4.x, XML, SFDC, MS excel, Power MHC, MS Word, MS Visio, MS .NET, XML, XSLT, MS SQL, MS FrontPage, MS Power Point.

Confidential - Richmond, VA

Sr. Business Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Facilitated JAD sessions for Requirement Validation with HPA to gather requirements for the new MMIS.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Analyzed and documented business and functional requirements via uses cases for Medicare billing transaction-based middleware/database layers with SOA & XML.
• Validating the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Prepared client process maps for the consumer, broker, employer and provider transactions for the Facets process.
• Designed and developed Use Case Diagrams for the Facets process modules.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X10 Transaction, Code set and Identifier aspects of HIPAA.
• Documented and tracked requirements in Mercury Quality Center.
• Designed and implemented HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction. Populated ICD-9, NDC Disease code sets as per the standards. Experience with transaction sets 835, 837, 270, 271, 276, 277 and 5010.
• Provided suggestions and ideas more from a strategic and long term perspective.
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Worked on EDI transaction 835 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Incorporated HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X10
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Involved in analysis for wide range of Six Sigma and Web-based initiatives, including user requirements.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database
• Analyzed and Documented Business Requirement Document (BRD), Functional Specification Documentation, and System RequirementDocumentation, using UML methodologies
• Conducted meetings to understand the workflow, their processes and assisted in gap analysis to derive requirements for existing systems enhancements.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Created technical design documentation for the data models, data flow control process, metadata management.
• Logged defects into QC while doing Functional Testing and followed through the process until the defects were closed.
• Reviewed the Defects entered by the QA team and prioritized the defects and assigned them to the development team
• Prepared UAT Materials, including the UAT Process, UAT Test document which would include step-by step process for UAT as well as all thetests that would cover all requirements.
• Worked extensively with the QA team for designing Test Plan and Test Cases for the User Acceptance Testing.

Environment: Windows XP Professional, Oracle9i, MS Access 2000, MS Excel, RUP, PL/SQL, SQL Server, Oracle, UML, Rational Rose, Informatica, Requisite Pro, Agile, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.

Confidential - Louisville, KY

Business System Analyst

Responsibilities:

• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Extensively worked on performing data profiling on the Facets data model which involved the eligibility, membership and claims data.
• Prioritize user stories and assigned to different sprints.
• Implemented RUP methodology of SDLC throughout the project.
• Facilitated daily stand ups and managed task board with user stories and board.
• Prepared and tracked burn down charts and velocity charts for timely delivery of projects.
• Prepared product backlog working with product owner and other SME.
• Efficiently interacted with designers and software developers to understand application functionality and navigational flow and keep them updated about business user's specifications.
• Involved in designing and defining User Interface Requirements (UIR) and visual patterns by creating wireframes, screen mockups and story boards.
• Coauthored initial project glossary and an initial business case, which included business context, success criteria (revenue projection, market recognition, and so on), financial forecast and an initial risk assessment.
• Developed understanding of various transactions involved in transition from HIPAA 4010 to HIPAA 5010 like Eligibility, Benefit, Claim submission transactions in Facets tables
• Analyzed and validated requirement for HIPAA 5010 and gathered requirement for ICD10.
• Analyzed and documented differences between the AS-IS and TO-BE processes.
• Worked on EDI 270/271 (Claim Eligibility Inquiry) /276/277 (Claim Status Check) /837 Claim Submission /835 (Claim Remittance) in Facets lifecycle.
• Developed mapping documents for ICD 9 to ICD 10 application.
• Performed UAT, Regression testing on EDI 835 and 837 X12 format in Facets.
• Analyzed all ICD10 codes and validated the outcomes.
• Supported User Acceptance testing (UAT) and collaborated with the QA team to develop test plans, test scenarios, test cases and test data to be used in testing, based on business requirements and application knowledge.
• Interacted with the developers to report and correct bugs.
• Created and maintained Issues Log and ensured timely resolution of all items

Environment: MS Office Suite, MS Visio, Agile - Scrum, Oracle, SQL, PL/SQL, Quality Center, Windows Server, Java, Java Script, Business Objects, Facets

Confidential, Dayton, OH

Business Analyst

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Working within a growing knowledge of X12 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Provided full life cycle support for company's Facets enhancement to Facets e2 Workflow and Network Management Suite with Pricing Modeler and Network Modeler application--including Business Requirement gathering, Functional Design, Technical Design, and Production Support documentation for multiple outgoing interfaces.
• Used Facets 4.31 to receive, store and send HIPAA-standard transactions (835, 837, 270, 271, 276, 277) and to administer HIPAA privacy rights.
• Participated in Facets Table data modeling; planning, designing, implementation of the data warehouse and conducted testing by developing complex SQL queries.
• Mapped provider data from source to target Facets 4.31 data layout for the claims and benefit configuration.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process
• Worked with the QA team in testing the upgraded system for data retrieval, using complex SQL queries.
• Validated the Business-to-Business data exchanges between data exchange partners; validate the internal processing of the MMIS, or other transaction processing system.
• Involved in meeting with Provider communities to discuss the conversion of the Legacy System to New MMIS system.
• Conducted a requirements study for replacing their Order Entry and Billing applications including a review of their Customer Service operation, web sales, and other e-commerce needs.
• Identified needed modifications for upcoming ICD9 directives from the then available documents from World Health Organization, and CMS
• Analyzed CMS comparison documentation highlighting changes of 4010 format and ICD9 diagnosis and procedure codes.
• 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 Enrollment hence analyzing and documenting related business processes.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Worked in all the different processes of Claims processing from Claim Online editing /processing /Adjudication /Payments systems
• Responsibility included interacting with the users and business relationship managers and implementing changes on the database in order to ensure approval.
• Responsible for creating different sessions and workflows to load the data to Data Warehouse using Informatica Workflow Manager.
• Worked with SQL Server and developed and ran SQL queries for data selection, cleansing and data mapping.
• Managed the transition to new development standards, procedures and processes including the introduction of UML, Rational Products including Rational Software Architect, ClearCase and ClearQuest as well as the Mercury Test Suite
• Responsible for data mapping of HL7 messages into relational database.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Assisted QA testing in formulating the test plans, reviewed QA test plans for appropriate test coverage and managed the Change request documentation for Change management processes.
• Developed business process models in RUP to document existing and future business processes.
• Used senior level SQL query skills (Oracle and TSQL) in analyzing and validating SSIS ETL database data ware house processes.
• Worked with business and system modeling tools such as Data Flow Diagrams (DFD), Process Models, Entity Relationship (ER) Diagrams, and Use Cases
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007,Agile, OOAD, ETL, QNXT, Facets 4.31, MS Office, SQL Server, MS Project, Oracle, T-SQL, MS Access, EDI, RF Tool, Scrum, Mercury Test Directory, Mercury QC, BI Toolset, CutePdf, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.