Summary

• Highly motivated and result oriented with 7 years of industry experience as Business/Systems Analyst in Healthcare Industry.
• Excellent in Developing and evaluating business process Models.
• Proven success as a business analyst through the years, providing a well-balanced understanding of business relationships, business requirements, and technical solutions.
• Deep understanding of enterprise data warehouses.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Experience in configuration of claims adjudication systems, i.e., Amisys, Facets, QNXT.
• Adequate knowledge in Health Administration Claims processing auto adjudication , COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP consumer driven health plans
• Deep understanding of HEDIS Reporting, Medical Record Abstraction, Quality Improvement, and Data Analysis.
• Extensive experience in conducting Market Research, Feasibility Studies, Data Analyses, Data Mapping, Data Profiling , Gap Analyses, Risk Identification, Risk Assessment, Risks Analyses, and Risk management.
• 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 with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Deep understanding of enterprise data warehouses.
• Expertise in GUI testing, functional testing, performance testing, UAT, unit testing, integration testing with the extensive knowledge of smoke testing, volume testing and stress/ load testing
• Solid understanding of Business Process definition, Risk Analysis and SDLC methodologies.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Proficient in the implementation of production change management techniques and service delivery disciplines
• Professional experience in business analysis, operations management and development, design, documentation and testing.
• Extensive experience in reviewing and understanding of Business Testing requirements and writing detailed Test Plans, Test Cases, and Test Scripts.
• Experience in implementing Microsoft Office SharePoint 2007.
• Advised management on improvement strategies, Competitive Profitability Analysis.
• Exposure to Client/Server, Web Application developmental tools and Software development and design.
• Extensive experience in Testing, Manual and Automated using tools Win Runner, Load Runner, Quick Test Pro, TestDirector, Rational Robot or Web and Client/Server Applications Mainframes

Software/Hardware:

C .Net, VB.Net, AS 400, Goldmine, SQL, IDMS, QTP, MS Windows NT 4.0/2000, Windows 95/98, Windows XP, MS Visual Studio.Net, IBM WebSphere 5.0, Power Builder 5, 6.5, 7, Rational Rose, UML 2.0 , RUP, OOAD, MS Visio and Visual Studio.Net, Sybase SQl Anywhere 5/6, Adaptive Server Anywhere, Crystal Reports, MSSQL 7, Oracle 6 / 7.x / 8i / 9i, Oracle TOAD, Informatica, SharePoint, Bbusiness Object, ETL, Cognos, Erwin ODBC, Visual Source Safe 6.0, Cobol, Source Off-Site, Round-Table, Win CVS, NUnit.net, MS Project, MS-Office

PROFESSIONAL EXPERIENCE:

Confidential

Role: Business Analyst

Responsibilities:

• Established the business analysis methodology using Rational Unified Process RUP technique
• Helped develop project plans and to manage project scope.
• Preformed regular sittings with stakeholders modeled system requirements through JAD/JAR sessions and maintained project stakeholder request baselines.
• Attended and conducted meetings and workshops to discuss high level requirements and developed User Requirements Specification Document.
• 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.
• Installation of major components for the Trizetto QNXT 3.4 medical record system including coordination of benefits for Dual Member and Dual coverage customers, Medicare Processing Refund, 837 EDI/ hardcopy claims input and 276/277 queries.
• Assisted in building the system analysis process model using Rational Rose.
• Identify, assess, and document system requirements, recommending business priorities, and advising business on options, risks, and costs.
• Performed System testing of the Claims processing systems Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment .
• Worked in all the different processes of Claims processing from Claim Online editing /processing /Adjudication /Payments systems
• Validating the EDI 837 claim billing professional, institutional and dental claims 835 remittance advice or payment claims adjudications.
• Analyze impact of proposed solution across the business, develop use cases to explain/demonstrate system requirements/specifications to IT team, and contribute a business and process perspective during design reviews.
• Implemented the Rational Unified Process RUP in terms of disciplines and phases, each consisting of one or more iterations.
• Involved in development documentation of Software Requirements Specification SRS and using Rational Rose.
• Utilized PL/SQL stored procedures, functions, packages and triggers and SQL queries programming to create business logic
• Developed strategies with Quality Assurance group to implement Test Cases in Mercury Test Director for stress testing and UAT User Acceptance Testing
• Prepared scenarios, Use Cases UML State Diagram for scenarios using Rational Rose.
• Created Use Case specifications, business flow diagrams, Activity/State diagram and Sequence diagram using MS Visio and object oriented OOA/OOD methodology.
• Conducted Joint Application Discussions JAD , project meetings, reviews walkthroughs, client interviews and coordinating various technical team at off shore and managerial teams at all levels.
• Performed GAP analysis of business rules, business and system process flows, user administration, and requirements
• Provided strategic support in development of detailed project plans, work assignments, target dates etc

Environment: Visio, Ms Project, Ms Office, RUP, UML, Rational Rose, requisite Pro, MS Visio, PL/SQL, SQL

Confidential

Role: Business Systems Analyst

Responsibilities:

• Studied business requirements and conduced User Interviews to identify and document the data discrepancies and their sources as related to Government Contract Compliance GCC , Government Disclosures, Government Pricing, Customers, Products, Product pricing.
• Responsible for developing applications for physicians' electronic billing and scheduling, and electronic medical records EMR .
• Successfully handled the testing of health care products like Epic Systems and EHR Electronic Health Record .
• Provided creative solutions to better meet client needs by anticipating, investigating and analyzing specific problems related to systems, networks, providers, eligibility, billing and pharmacy.
• Analyze, and document business and functional requirements via uses cases for Medicare billing transaction-based middleware/database layers with SOA XML.
• Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM Health Trans and Claims Accumulation and Adjudication is done through Diamond.
• Created specifications for EDI HL7 A28, A31, ADT and X12 837/835 transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Supporting client's HEDIS Processes and Reporting needs, and helping them to reach new levels of performance.
• Worked on requirements and completely developed the new process for HEDIS data processing.
• After Executive confirmation did Gap analysis to assess needs that could not be met by core EHR.
• Worked on Electronic health record system as a CRM web based application.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Worked on Claims Processing per Medicaid Management Information Systems MMIS 42 CFR 433.
• Created Business Requirement Document BRD , Functional Requirement Specification FRS document, User Requirement Specification URS and Change Request CR document for system application development.
• 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.
• Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
• Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
• Responsibility included modifications to a customer's mainframe system to support new product features or regulatory requirements and, in some cases, involved a system upgrade
• Converted Business Requirements to the Functional Specification and Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Use Cases and other Process Flow Models were designed using Visio and Rational Rose.
• Helped in developing QA Test plans for Systems integration and System Testing. Performed Black Box Testing. Performed GUI testing and user acceptance testing UAT .
• Identify Member, Provider, Coverage, Medicare, and Medicaid
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Established a RUP Rational Unified Process centric business analysis methodology.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams and ER Diagrams in MS Project.
• Automated confidence tests that run on new builds on regular basis.
• Managing overall testing process and project to production change management life-cycle.
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.

Environment: Windows 98/2000, Window2003, Window NT, Linux, Mainframe, Solaris IBM Web sphere, Load Runner 8.2, Oracle 8i/9i/10g, SQL Server 2000, DB2, Toad, MS-Project 2000/2003.

Confidential

Role: Business Analyst

Responsibilities:

• Conducted status report meetings with the business and the IT team on a weekly basis, as the most important aspect of the project was Data Mapping.
• Mentored and Knowledge transfer on how to create and implement test assets in RQM Test Plan, Test Case, Test Scripts, Test Execution Records, Test suites, how to execute test and report on the test result using RQM Reports.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System MMIS
• Recorded retention stored in Knowledge Link. Ad Hoc reporting, Admin for MS Project, Excel dbase and pivot tables, Clarity and MS Project Server Admin duties.
• Developed and maintain information and documentation related to developing and modifying business processes and systems.
• Validated the HIPAA/EDI transactions, tested the claims processing and Adjudication EDI 837 EDI 835 .
• Established a Business Analysis methodology around the Rational Unified Process.
• Designed the online screens and reports for the Medicaid Online Electronic Claims Submission System.
• Analyzed, designed, and coded several online subsystems for the Medicaid System.
• Assisted in building a Business Analysis Process Model using Rational Rose and Visio.
• Performed extensive Requirement analysis and developed use cases and workflows.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Documented business workflows textually as well as in UML diagrams State diagrams according to RUP, for the stakeholder review.
• Introduced Agile and RUP methodologies to reflect liquid nature of front-office improving time-to-market
• Provided clear and concise documentation regarding requirements management plans, Functional Requirements, supplemental Requirements, Test Plans and Test Cases.
• Provided key input in working with users in defining project and system requirements.
• Developed strategic partnerships with the business units to develop a solid knowledge base of the business line including the business plan, products, and process and revenue streams.
• Documented and delivered Functional Specification Document to the project team.
• Developed Use Case driven test scripts using Mercury Quality Center.
• Developed business requirement specification documents as well as high-level project plan.
• Involved in Data Modeling of both Logical Design and Physical design of data warehouse and data marts in Star Schema and Snow Flake Schema methodology.
• Conducted benchmarking activities to identify best practices.

Environment: Mainframes, COBOL, JCL, Db2, Oracle, Crystal Reports, Rose, Mercury, Lotus Notes, ETL, Perl, MS MS Excel, Word, MS Excel, MS Visio, LoadRunner, WinRunner

Confidential

Role: Business Systems Analyst

Responsibilities:

• Met with various HMO, PPO, Medicaid/Medicare, and Tricare / Champus Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues
• Integrating systems of record into conformed dimensions and fact tables. Involved in analyzing the claims on basis of Primary and Secondary Payers and performed Medicare subsidy eligibility check for employee group plans.
• Responsible for writing Functional Requirement Specifications FRS and User Requirement Specification URS .
• Prepared project plans using MS Project and coordinated timelines as guided by the Project Manager
• Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
• Conducted UAT facilitated discussion between business team and QA team on determine the test requirements and pass/fail criteria documented and reported user feedbacks to management team.
• Prepared automated generic Test Scripts and Functions using Rational Robot for functional/GUI and regression testing
• Experience with data migration ETL development , document data manipulation processes and scripts Developed detailed use case models and supporting specifications.
• Involved in decision making of converting manual test cases into automated test scripts and analyzing their life time and time required to update the scripts.
• Used Castor to create objects from XML documents. Involved in Logical Physical Data Modeling. Database Schema design and modification of Triggers, Scripts, Stored Procedures in Sybase Database Servers.
• Reported and analyzed all application defects, user issues and resolution status to the higher manager using Mercury Quality Center..
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language PL/SQL .
• Responsible to import the data from Crystal reports by using Business Objects Live office into Microsoft Excel and Word.
• Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
• Created use cases, activity diagrams and process diagrams using Microsoft Visio. Validate test plans/scripts and perform final reviews of test results. Environment: Rational Rose, Clear Quest, Microsoft Project, Crystal reports, SharePoint, Mercury, Lotus Notes, Erwin, Microsoft Visio, Microsoft Office suite, Business Objects, ETL, Oracle, Windows NT, Mainframes, COBOL.

Confidential

Role: Business Analyst

Responsibilities:

• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Produced UML Activity diagrams with defined swim lanes using MS Visio as part of claims process analysis
• Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design UI screen using Microsoft Visio.
• Upgraded the existing Test Scripts and created new scripts for client application to be able to work for new versions and patches, which improved product quality.
• UAT testing performed along with call center managers to make sure that application meets their requirements.
• Accumulated system requirements from various departments through surveys and interviews.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Conducted JAD sessions with management, SME, vendors, users and other stakeholders for open and pending issues.

• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams and ER Diagrams in MS Project.
• Worked in broad range of technologies, including business process tools such as Microsoft Project, Primavera, Promodel, MS Excel, MS Access, MS Visio, technical assessment tools, Data Warehousing concepts and web design and development.

• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Involved in writing the detailed Test Plan using Mercury Quality Center, after analyzing business requirements and software/functional requirement artifacts.
• Worked extensively with MS Excel and MS access
• Suggested measures and recommendations to improve the current application performance.

Environment: Rational Enterprise Suite Rose, RequisitePro, ClearCase, ClearQuest , MS Office, Oracle, DB2, Sybase, SQL Server Reports, WinRunner, LoadRunner, Quick TestPro