SUMMARY

• Sr. Business Systems Analyst with 8 years of industry experience in identifying business needs, and determining solutions to business problems for complex software projects including system development component, business process improvement, strategic planning and policy development in Healthcare sector
• Experience in creating and organizing deliverables in a secure retrievable area: such as BRD Business Requirement Document , FRD Functional Requirement Document , PDD Project/ Product Definition Document , SRS System Requirement Specification and Change Management Documents.
• Experience with full Software Development Life Cycle SDLC and project life cycle including Feasibility Analysis, Requirements planning and Management, Application Design and Development, Testing, Implementation and Post-Implementation Validation, and Solution Assessment.
• Good knowledge of Business Intelligence, Data Warehousing and Business Architecture.
• Extensive experience in Medicare Part D/PBM and Medicaid.
• Good knowledge and understanding of Medical Management Information System MMIS
• Documenting and creating Test Plans, Test Objectives and Test Cases. Also involved in maintaining Test Matrix and Traceability Matrix.
• Strong knowledge of Object Oriented Analysis and Design OOAD using Unified Modeling Language UML , Rational Unified Process RUP , Capability Maturity model CMM , Six Sigma DMAIC .
• Well versed with FACETS, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Also worked using various methodologies such as Waterfall methodology, Agile Software Development, Joint Application Design JAD , and Prototyping.
• Experienced in Business writing skills and Technical writing skills in developing Business Case, Scope Document, Use Case Scenarios, Test Plans, Test Cases, AS-IS and TO-BE workflows.
• Proficient in Rational Suite including Rational Rose, Requisite Pro, MS Visio, MS Project and MS Access.
• Broad knowledge of Medicare, Medicaid, PPO, HMO, POS, diagnostic codes, and claims process, EDMS electronic data management system .
• Excellent knowledge of Health Insurance Portability Accountability Act HIPAA standards, Electronic Data Interchange EDI , and Implementation and knowledge of HIPAA code sets, ICD-9, ICD-10 coding, and HL7.
• Understand rules and regulations of HIPAA as imposed during Various Electronic Data
• Interchange EDI transactions- 837 Claims and Encounters, 834 Benefit Enrollment and
• Claim Status Request / Response.
• Response, 277/275 - Claim Request for additional Information and Response, 276/277
• Maintenance, 835 - Claim Payment/Advice, 270/271 - Eligibility Benefit Inquiry and
• Excellent communication skills and proficiency in interacting with the stakeholders, and Subject Matter Experts SME's to get a better understanding of the Business Process.
• Extensive experience with Business Process Management BPM system.
• Good knowledge of PPACA Patient Protection and Affordable Care Act and HIX.
• Efficient in handling Change Requests by the client.
• Experience in User Acceptance testing, White Box, Black Box, Unit, Functional, Integration, Back End and System Level Load and Stress Testing for many types of applications including web and client server applications.
• Working knowledge and experience with SQL/PL SQL, HTML, and MS Access
• Excellent analytical and problem solving skills in designing, developing, and implementing innovative business processes using new approaches and technology.

SKILLS

• Microsoft Tools MS Project, Visio, Excel, Word, Outlook, PowerPoint, MS Excel, SharePoint
• Requirements Management Tools Rational Requisite Pro, Rational Rose, MS Visio, Share Point, IBM-Blue Works Live.
• Operating System Windows 2000/7/XP, DOS, UNIX
• Business Skills Business Process Analysis Design, Process Improvement and Implementation assessment, Requirement Gathering, Use Case Modeling, JAD/JRP Sessions, Gap Analysis, Impact Analysis.
• Languages/Standards SQL, JAVA, XML, HTTP, HIPPA 4010/5010, ICD9/10, ANSIX12, CPT, CMS form, Six Sigma.
• Methodologies Rational Unified Process RUP , Agile, Waterfall, Rapid Application Development RAD
• Other Tools Axure, Magic Draw, Informatica, Cognos, Visual Basic, BWL, Mainframe.

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business Systems Analyst

• Providing local solutions that improve access to affordable, quality healthcare, each of the 37 independent and locally operated Blue Cross and Blue Shield companies deliver health insurance coverage for nearly 105 million members across all 50 states.
• Project: In this project Horizon purchased an application consisting of Pricer and Payment Bundling Administration. The implementation of these applications aligns with the enterprise goal of Horizon becoming an active player and a potential leader in future capabilities such as episode of care organizations and patient centered medical homes. This application is a Trizetto product called NetworXpricer which is a rule-based claim pricing and processing system.

Responsibilities:

• Interacted with stakeholders and SMEs to gather requirements as per the business needs.
• Created workflows for each department, activity diagrams and sequence diagrams to analyze the requirements and recommend solutions. Involved in creating use case diagrams activity diagrams and state diagram using the architectural chart.
• Created and migrated all the future state process flows and flow charts to Blue Works Live IBM tool. This is replacing MS Visio in Horizon.
• Facilitated Joint Application Development JAD sessions with all different work streams for communicating managing expectations and to discuss various means for integrations for the new system.
• Planning multiple sprint sessions on daily basis. Working in an agile environment.
• Organized meetings to discuss outstanding issues with the IT pricing team, NASCO, JAVA, MOM and RSLU teams on daily basis.
• Creating and implementing a high level of Technical Operational Effectiveness Plan documentation.
• Documenting and describing all the technical aspects and all of the technical roles and responsibilities in different teams involved in the Operations Support Phase of this implementation.
• Created and documented a Business Operational Effectiveness Plan BOEP to annotate the business processes and procedures required to support the NetworX Pricer Integration project on a daily basis.
• Interacted with business heads to finalize the Business Requirements for the application.
• Verified and validated all the build or release related issues and resolve then through discussion with business analysts with the users approval.
• Provide advanced problem solving and functional support, and work with the team to resolve complex functional problems.
• Used Microsoft SharePoint, Lotus Notes and CQ as the version-tracking tool for managing the requirements documentation.
• Worked in the Contract Term Repository work stream to store and manage the provider contracts and integrate it with new Pricing Solution.
• Verified different types of codes from NASCO and implementing them in the existing claims and configuring it to an error or warnings if required. . Whether the issue needs to triaged or creating a PLog or IM tickets is needed.
• Implemented On-Line Desk Levels ODL for the process codes, criteria, and work instructions for the responsible teams.
• In the BOEP document I included the normal day to day process flows, procedures and escalation paths associated with possible issues encountered, including description of daily operational activities.
• Involved in managing the Daily Standup meetings and also ensured that quality standards were enforced as per the build-release schedule.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Managed changing requirements which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Environment: Agile methodology, MS Visio, MS Project, Lync, Win Runner, Microsoft Outlook, Microsoft Office, Microsoft Excel, Microsoft Word, Microsoft Share point, Blue Works Live-IBM.

Confidential

Sr. Business Systems Analyst

• Confidential, is dedicated to providing member, clients and healthcare professionals with services that deliver safe and affordable pharmaceuticals.
• Project: In this project Express Scripts wants to improve its Claim Reimbursement User Interface for a better user experience and incorporate changes from ICD 9 to ICD 10.

Responsibilities:

• Gathered requirements for impacted system and business areas for ICD-10 and their needs to embrace the changes.
• Compiled the Vision Document and composed detailed Use Case Specification Documents in Rational RequisitePro.
• Used UML to perform Use-Case analysis to capture the dynamic aspect of the application.
• Interacted with stakeholders and gathered requirements as per the business needs.
• Adhered to existing change management procedures. Recommended improvements to existing procedures.
• Facilitated Joint Application Development JAD sessions with all IT groups for communicating managing expectations and to discuss various means for integrations with current system using an adoption through execution strategy and to collaborate resource allocation and project completion.
• Developed high level Design and Development Recommendations and prepared ICD-09 to ICD-10 Code Diagnosis and Procedure Mapping documents.
• Created activity diagrams and sequence diagrams to analyze the requirements and recommend solutions. Involved in creating use case diagrams activity diagrams and state diagram using enterprise architect.
• Involved in the planning of the sprint sessions and documenting of the artifacts throughout the various phases of the development process.
• Ensured the accuracy and consistency of the data during the data loading process.
• While working with various members at the management level to understand the business process and decision models, was also involved in Compiling the Vision Document and composing detailed Use Case Specification Documents in Rational RequisitePro.
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Conducted GAP analysis by understanding the AS-IS system and the TO-BE system requirements by having discussions with the SME's.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Documented Requirement Traceability Matrix in Microsoft Excel for traceability of requirements through test cases.
• Extensive use of FACETS backend tables and front end application system for data validation purposes.
• Developed Flowchart and process diagram using Microsoft Visio.
• Was in regular contact with Business partners on the status of issues, action plans and timeframe for resolution throughout the development cycle.
• Performed User acceptance testing UAT
• Responsible for defect tracking and reporting using Quality Center.
• Organized meetings to discuss outstanding issues with QA team and developers.

Environment: Rational RequisitePro, UML, Agile, Microsoft Office Project, Publisher, Excel, Word, PowerPoint, and Visio , Project Manager, Facets, Issue Tracker, BI Applications, MS Outlook, SDLC, Oracle 10g, MS SharePoint, Quality Center.

Confidential

Systems Analyst

• The Confidential is continually working to improve health care access and outcomes for its customers providing best possible care in minimal cost thus improving health care costs, client experience and maintain effective internal and external relationships with its customers.
• Project: As a Business Analyst in the State Department, I was involved with HIPAA 5010 compliance for the new MMIS system. The project also involved performing gap analysis and identifying the changes in HIPAA 5010 to upgrade second web portal to comply with the new standards approved by the Health Insurance Portability and Accountability Act HIPAA , all of this consisted of applying gap analysis, compiling the results achieved and screening them.

Responsibilities:

• Gathered Business Requirements from all the stakeholders and interacting with the providers, managers, developers to develop the business Processes.
• Extensively developed project documentation, process flow documents, formal proposals, RFQ's and RFP's. Formulated methodologies and developed SDLC phases, strategies, time cost estimates with milestones for each phase.
• Prepared Business Requirement Documents BRD's and Functional Requirement Documents FRD's from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Conducted Risk Analysis and Impact analysis whenever there is any change in the business requirement and continually updating the business requirement document.
• Conducted JAD sessions and ultimately reducing the time spent in moving all the information from stakeholders and other team members.
• Perform GAP analysis in order to identify the changes in 837, 270/271, 275, 276/277, 834 and 835 transactions being proposed in the upgrade from HIPAA 4010 to HIPAA 5010.
• Complete understood the business process to determine the needs of the business.
• Assisted in the meetings with the technical team as well as the clients regularly to assess the current process and how it could be changed in making a better proposed process.
• Provide various strategies to implement HIPAA 4010 in the new MMIS system and ultimately move to HIPAA 5010.
• Performed six-sigma process during the project to eliminate any defects in the process.
• Develop spike requirements solution for all the current problems and UI prototypes for capturing the requirements.
• Helped in developing test cases such as test plans and test scenarios.
• Utilize Agile Methodology and build different phases of software developmental cycle.
• Actively involved in designing EDI transactions using the new HIPAA 5010 version and ICD -10 codes and analyzing HIPAA compliance and EDI transaction.
• Recommending actions against the action plans during the ongoing progress of the project to the project manager.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Assisted Project Manager in creation of project management plans to manage timely delivery using MS project.
• Created Requirement Tractability Matrix RTM to track and maintain stakeholders requested requirements and changes.
• Involved in creating test plans and test specifications as per business requirements.
• Participated in the bug review meetings.

Environment: MS Project, Agile, Requirement Traceability Matrix RTM , Rational Rose Test, JAD, , MS Visio, Windows OS, MS Office, SharePoint, ETL, Server, Quality Center, SQL Sever

Confidential

Sr. Business Systems Analyst

• Confidential is one of the leading healthcare providers in Quad cities and Dewitt.
• Project: The scope of this project was to implement a web based Claims Processing and Management application to manage health insurance claims electronically. This software is a web-based electronic claims processing solution providing real-time patient insurance information. The application connects the organization to the largest all-payer network of commercial and government health plans nationwide to provide a wealth of real-time patient benefit information. Data is automatically translated to meet HIPAA compliance standards and the privacy of transactions is protected with the highest level of internet-based security. The whole process of claim processing adhered to HIPAA 5010 compliance where the systems needed to upgrade from 4010 version to 5010 version. Also worked on Medicare Part D/PBM liaison team with the Pharmacy Benefit Manager for defining business rules for claim adjudication.

Responsibilities:

• Analyzed the Business Modules and their impact on the current system.
• Performed requirement gathering analysis by actively soliciting, analyzing customer requirements
• Created BRD and FRD to be used by IT Team after conducting Interviews with End Users, JAD Sessions and analyzed their current systems.
• Created Use Cases, Use Case Models, Work Flows, and System Specification Document Using Agile Methodology.
• Used Component business modeling for improving strategic planning and efficiency.
• Assisted with building EDI 837 I, D, P , 835, 270/271 transactions processing flow from the Trading Partners to the translator to the Mainframe and back to the Trading Partner.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 HIPAA 5010 formats.
• Identified AS-IS processes of claims transactions of 4010/4010A standard and TO-BE processes ICD-10-CM and ICD-10-PCS compliance requirements of 5010 standard using the gap analysis and develop actions to fill those gaps.
• Involved in understanding the business logic, designing requirements, communicating them to the developers, generating documentation, designing use cases, creating various diagrams like State Diagrams, Sequence Diagrams as part of project.
• Maintained Traceability matrix throughout the project.
• Created standards / guidelines for business process modeling, Use Cases, Work Flows, Data Dictionary, and requirements specifications.
• Mentoring end-users on requirements specifications techniques and the software development life cycle.
• Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy.
• Created transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837- I, P, D , 835 Remittances and others. Resource for UB92 and HCFA1500 billing formats transaction sets requirements, EDI development and Design, X12 protocols through Version 4010A1 and newer, conversion needs and understanding of legacy EDI formats, such as UB92 Versions 4, 5, 6 and NSF.
• Analyzed requirements and formulated a Test Plan for testing the functionality, navigation, and integration testing of the application.
• Did research on Member, Provider, Claims, Authorization, Appeals and Grievances data from FACETS back end and front end application system for reporting purposes.
• Bug Reporting Tracking the status in HP QC.

Environment: UML, SQL, Windows Server, Java, HTML, Agile, Facets, Excel, MS Visio, MS Project, Power Point, Share Point Server, Quality Center, Outlook, SQL Server.

Confidential

Business Analyst

• Confidential has committed them to provide broad, useful and competitively-priced insurance products and services to meet their customers' ever-changing needs.
• Project: The main aim of the project was to perform system upgrade of the existing website to include the suggestions provided by the user feedback while adding the ability to request and view prior approvals online, expanded claims inquiry and reporting options and optimized user security technology.

Responsibilities:

• Developed and pruned the artifact repository and templates.
• Conducted JAD sessions with extensive involvement from Business, Development, Testing teams, Architects, SME's Subject Matter Experts and Managers of various Business Units.
• Instrumental in writing the Business and System Vision documents, Business and System Use Cases, Supplementary Specifications and extracting Stakeholder requirements.
• Responsible for rating multi-line policies. Manual rated Property, Liability, Auto and Workers Compensation policies. Conducted training classes for Auto and Workers compensation rating.
• Supported full traceability among all artifacts throughout the software development life cycle.
• Practice agile methodology, lead sprints and prioritize line items based on key business initiatives.
• Realized Use Cases and their corresponding activity flows with complete entity relationship, recording all flows in Rational Rose and using Clear Case for Version Control. Generated reports for the realized Use Cases in Rational Rose, using Rational SoDA for Word.
• Extracted the Business Requirements during various sessions with business leads and tagged all requirements in RequisitePro, tracing them all the way to the stakeholder requirements.
• Designed conceptual and specification methodology using Object oriented analysis and design OOAD methodologies based on UML Unified Modeling Language .
• Extensively involved in integrating existing models for various LOB's Lines of Business and highlighting issues due to abstraction of Use Cases from Process Flows.
• Extensively involved in performing Gap Analysis in the upgrade of the existing Claims Processing system and highlighting related issues.
• Co-ordination with multiple teams and integration architects, in performing analysis for issues regarding speed and stability.
• Interfaced with Artifacts and Solutions delivery teams to provide input for planning a Web-based Architecture.
• Extensively involved in performing the SIT System Integration Testing and UAT User Acceptance Testing testing of new system.

Environment: Rational Analyst Suite Requisite Pro, Rose, Clear Case, Clear Quest , Agile, PVCS, MS Word, MS-Outlook, Excel.