SUMMARY:

• Results - oriented professional with good communications, team building, analysis and problem solving skills including 7+ years experience in Business Analysis, and client relationship management.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Expertise in Business Process Modeling, Business Process Re-design and in designing Process Architecture.
• Strong experience in RUP Business Modeling process.
• Experienced in Facets working with Provider Life cycle, Members Enrollment process, Claim processing and other data models.
• Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270, 271 for healthcare benefits and eligibility, 276, 277 for claims status and 278 for transmitting health care service information.
• Experience in configuration of claims adjudication systems, QNXT 3.4.
• Proficient in HP ALM Quality Center, IBM Rational Clear Quest and Rational RequisitePro for test designing, requirements mapping, traceability matrix, reports, test execution anddefect tracking
• Expertise in UML (class diagrams, object diagrams, GAP Analysis, use case diagrams, state diagrams, sequence diagrams, activity diagrams, and collaboration diagrams) as a business analysis methodology for application functionality designs using IBM’s Rational Rose.
• Familiar with EDI (Electronic Data Interchange), HL7 and ActiveX interfaces.
• Experience with RUP, UML, and AGILE (Sprints), Waterfall, Scrum.
• Knowledge of MMIS (Medicaid Management Information System), HIX (Health Insurance Exchange), EMR (Electronic Medical Record), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA), Emergency Medical Treatment and Active Labor Act (EMTALA).
• Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Extensive knowledge of Medical Management Information Systems (MMIS), and National Provider Identification (NPI).
• Proven expertise in creating test plans, UML diagrams, flowcharts, screen mockups and systems requirements specifications.
• Responsible for EDI strategies enabling Health Care Providers and Insurance Careers to communicate effectively.
• Strong knowledge of FDA QS 21 CFR 820, 211 for Pharmaceutical, Life Science and Health Care Industries and cGMP, GCP, GLP, CAPA, GRP, EMR, EHR & QMS.
• Good working knowledge in Claims processing, Medicare/Medicaid, HIPAA Regulations, Facets and 276, 277, 837P, 837I, 837D, 835 and 834 EDI Transactions for health care industries.
• Solid understanding of Business Process definition, Risk Analysis and SDLC methodologies.
• Excellent in Developing and evaluating business process Models.
• Solid hands on experience in HP ALM Quality Center Admin module to create custom fields, create new users, user groups with appropriate access level
• Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
• Advised management on improvement strategies, Competitive & Profitability Analysis.
• Excellent in Business proposal Risk Assessment. Highly effective management and organizational skills with ability to prioritize.
• Exposure to Client/Server, Web Application developmental tools and Software development and design.

SOFTWARE EXPERTISE:

Operating Systems: Windows 95/98/2000/XP, Macintosh, UNIX

Modeling Tools: MS Visio, MS Studio, True Comp

Modeling Languages: UML, OOAD, Object Modeling, RUP, AGILE

Programming Languages: SQL, PL/SQL, Java, .NET Framework, C#, Visual Basic

Database Management Systems: Oracle9i, MS Access, MS SQL Server, TOAD

Microsoft Tools: MS Office, MS Front Page, MS Outlook, MS Project, MS Visio

Rational Tools: Rational Rose, RequisitePro, Clear Case, Clear Quest

Testing Tools: Test Director, Quick Test Pro, Mercury Quality Center, HP Quality Center/ALM.

PROFESSIONAL EXPERIENCE:

Confidential, North Richland Hills, TX

Sr. Business System Analyst

Responsibilities:

• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Conducted user interviews and documented business and functional requirements.
• Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
• Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, Websphere and Cognos.
• Worked on health information exchange (HIE).
• Worked on Health Insurance Packaged Application like QNXT. Providing US Health Insurance domain and TriZetto's QNXT 3.4 training & mentoring to other internal Business Analysts and Entry level fresher’s including knowledge of conversation from earlier versions of QNXT. Extensively worked with QConnect.
• Worked on Facets to help payers efficiently execute core administrative functions, including claims processing, premium billing and customer service.
• Set up and configure HP ALM (QC) management tool to organize user groups, set standards for requirements, testing and defects reporting
• Involved in HIPAA EDI transactions such as 270, 271,837 (P, D, I), 276, 277, 834, 820, 278,999/TA1, and 277 CA.
• Designed Medical and Behavioral Health test scenarios for different phases of QA and UAT testing cycles using various parameters like; Member’s information - from different LOB’s (Line of Business) - Medicare, Medicaid, HMO, PPO, EPO, and POS; Different POS/TOS combination - with corresponding ICD and CPT codes; and Vendor / Provider Status - for both
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.
• QNXT Configuration and Maintenance/QA Activities included: Addition/Removal of CPT/HCPCS/Rev/ICD 9/Procedue codes/Custom fees/Restriction and Service Groups in a Benefit/Contract term. Also, addition and updating of Contract Terms (Change in reimbursement fees like daily rates) with the state specific revised rates of fee schedules.
• Worked with Facilities to get the correct count on number of Members/ Eligibility and Demographic information to set Groups/Subgroups/Subscribers/Members accurately in facets.
• Managed the product backlog and change request log for B2B applications using Excel.
• Created requirement documents for the development of the new HIX connector product that would integrate the exchange enrollment data with the existing core applications.
• Created HP ALM Quality center Training document.
• Introduced Agile to the product team and organized releases into SCRUM sprints, incorporated elements of XP
• Requirements Gathering/Documentation - Designed and documented detailed business requirements, functional requirements utilizing PMO & Governance approved templates.
• Created Test data and test cases in MS Excel to test numerous scenarios, for setting up Providers in FACETS.
• Worked with Facets Architects to get in-depth knowledge on Providers life cycle and how can Members and Claims get affected with Providers Network setups.
• Participated in HIX (Health Information Exchange) with State Business Leaders, for defining broader scope which will offer a mechanism by which patients, physicians, public health officials and researchers will be able to access data and actionable information, to allow them to demonstrate measurable improvements in health care quality, safety, efficiency and population health.
• Created a Mapping document to map Codes provided by Vendor/Roster/Government owned Facilities to match the codes that are acceptable in Facets.
• Identified the requirements that go in each sprint, collect them in the sprint backlog and collecting and managing the requirements that are not part of the current sprint into the product backlog.
• Utilize MKS Integrity 2009 for Software Lifecycle Management (SSLM) and Application Lifecycle Management (ALM).
• Led JAD session with IBM and IT System staff to include the EDI transaction sets; and quote to cash sales process into the ERP claims process. The system upgrades were implemented.
• Played key role in System Development Life Cycle Process consisting of: Design and Gap Analysis, Business Requirements, Systems Requirements, Test Criteria, and Implementation to have the outputs of project dealt with the automation of correspondence directed to Insurance policy owners.
• Designed High level design, for New process, integrating with legacy and Facets
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Created use case scenarios and documented work flow and business process using Rational Rose
• Wrote test cases and test scripts for the User Acceptance Testing (UAT).
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Queried database using SQL for backend testing
• Used Rational clear quest for defect management

Environment: Visual C++, SQL Server, UML, Facets 4.71, Agile / Srum Sprint, Sprint Backlog, MS Office Suite, Test Director, Visio, Rational Clear Case, Clear Quest.

Confidential, Pennsylvania, PA

Business Analyst / System Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Provided support to CMS/ Federal and State stakeholders on objectives relative to PPACA -HIX by performing the following duties in an agile (scrum) SDLC environment.
• The goal of the project was to create, EDI transaction data maps with its clients and business partners. The outcome was transaction maps were created.
• Wrote online training manual of EDI transaction maps.
• Created reports using Microsoft SQL Server 2005 Reporting Services and QNXT 3.4 tables
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT that would take several man hours to complete via the front end software.
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Created detailed Use cases, activity diagrams and flowcharts based on requirements gathering.
• Involved in configuration of Facets Subscriber/Member Application group
• Analyzed the member/eligibility information on claim to that in Facets.
• Created test data for testing in Facets development client.
• Resolved issues like member duplicated in file, dealing with dependent transaction if subscriber is not found, failures in submissions in QNXT.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintainace), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).
• My role was to assist the Project Management Office (PMO) in the development of an Enterprise-wide, web-based guidelines for Rational Unified Process.
• Followed the Rational Unified Process (RUP), Agile methodology and Extreme Programming concepts for project development. Analyzed and incorporated User Stories in different release plans for the sprints in Scrum process.
• Performed GAP analysis to identify AS-IS a process EDI transaction set 834,837 and 835 of 4010A and TO-BE processes of 5010 standard and based on that developed Business Requirement Documents.
• Worked on Facets to help payers efficiently execute core administrative functions, including claims processing, premium billing and customer service.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Identified and documented data model processes and system deficiencies for the HIX eligibility & enrollment.
• Utilized corporation developed Agile SDLC methodology. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) software.
• HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278.
• Worked with NASCO teams to get current work flow for detailed business process.
• Evaluated and analyzed EDI transaction sets 276/277 (Claim Status Request/Response), 270/271 (Eligibility Inquiry/Response), 837 (Claim Transaction) and 278 (Healthcare Service Review Information)
• Organized local meeting to promote and introduce new environmental products
• Wrote Test Cases and performed User Acceptance Testing (UAT), documented the in detail defects using the Defect Tracking report.
• Performed smoke test and Functional testing on the Sprints as and when they were delivered to the QA team
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.

Environment: OOAD, UML, RUP, TQM, Facets4.61, Agile / Srum Sprint, Sprint Backlog, Business Modeling and Data Modeling Rational Rose, Agile, Rational Requisite Pro, MS Visio, Clear Case, Clear Quest

Confidential, Baton Rouge, LA

Business Analyst

Responsibilities:

• Conducted one on one sessions and team meetings with the team leads and SME’s to understand the business requirements.
• Preparing System Test Cases from functional and technical requirement and Use case documents and performing System Testing.
• Trouble shooted file transmission problems and assisted customers in a call center environment with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (837P, 837I, 837D, 270/271).
• Understood the healthcare plans offered, including Medicaid Managed Plans such as Children and Adolescent Care, Women’s Preventive Care, Maternal Care, Asthma Care, Diabetes Care, Cardiovascular Care, and Mental Health.
• Defined overall Architecture for EDI transaction for real-time and batch process
• Have worked with Chevron, delivering Regulatory (EPA) Reporting strategy for Corporate Health & Environment Safety.
• Implemented RUP and followed iterative, Use Case driven process for requirement documentation and deployment.
• Involved in making Use Case Diagrams, Activity Diagrams, and using analysis and design models tools like MS Visio, Rational Rose through RUP, Agile and Waterfall Model
• Worked with SME close to understand Claim Adjudication Process setup in Facets.
• Followed the standards of PMO which included getting approvals for SOX Compliance at various Gates.
• Responsible forMedicaid ClaimsResolution/Reimbursement for state health plans usingMMIS.
• Prepared the Charter/BUR and functional design document.
• Monitor departmental policies, processes, and procedural compliance for both in-house and client sites to ensure proper adherence to budget and safety standards
• Experience with Medicare and Medicaid: Claims processing, Membership, and Eligibility Verification and care management.
• Thorough knowledge of Eligibility and membership Affairs. Also knowledge of HIPAA, X12, and HL7 standards and Medicaid provider best practices.
• Updated the functional design document for NPI related changes in the Encounters project.
• Applied Unified Modeling Language (UML) methodologies to design Communication Diagram, Use Case Diagrams, Activity Diagrams, Sequence Diagram, ER diagrams & Data Mapping
• Analyzed encounters claims file (837 P, I, D) using SpecBuilder.
• Created SQL queries to check the updates in Oracle database and executed SQL queries in Oracle to check the redundancy of data. Setup runbook for Inbound and Outbound EDI transactions.
• Developed business level activity diagram utilizing UML (according to Agile Unified Process) to visualize use cases, identified gaps between the current model and future model.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Conducted JAD sessions with the participation of the users and the stakeholders to gather requirements.
• Utilized corporation developed Agile SDLC methodology. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
• Trained new Business analysts about the system and the data model.

Environment: MS Project, Windows NT,, Microsoft Office SharePoint Server 2003, Agile, Microsoft Content Management Server, ASP .NET, IBM DB2 data server, MS Office, MS Visio, Test Director.

Confidential, Jacksonville, FL

Business Analyst

Responsibilities:

• Analyzed user requirement documents (URD), software requirement specification document (SRS) and prepared System test plan by dividing the application into manageable units.
• Involved in writing Detailed Test Plan for the Application under Test (AUT).
• Implemented a modified RUP process for managing requirements
• Enhanced the Test Cases by analyzing the Specification Documents.
• Developed and maintained hundreds of programs for the Blood Inventory System to ensure the safety of the blood supply for all regions using our system
• Collected and processed quantitative and qualitative data analysis.
• Prepared spreadsheets with the help of MS Office Excel to show like specific geographic regions etc.
• Analyzed business and technical requirements, thus creating the Business Use Case and Functional Use Case documents.
• Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
• Conducted several demos driven by MS PowerPoint Presentations.
• Reported status to the project manager weekly.
• Involved with the business users, developers to make sure the reports were developed right to the specification.
• Documented existing applications with the creation of UML sequence diagram and class diagram to document.
• Involved in creating use case diagrams for the purpose of the team to understand the workflow of the system.
• Involved in the User Acceptance Testing to make sure the defects raised by the business users were resolved up to the Management Expectation by the developer group. Prepared documentation using MS Word.
• Created reports in MS WORD for account processing of each client group.

Environment: MS Access 2000, MS Excel, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.