SUMMARY:

8 years of experience as a Business System analyst in Healthcare and Insurance domain. I am a creative and aggressive self-starter with integrative thinking skills, capable of creating and maintaining positive and productive working relationships in internal, external, independent and team environments. Having worked through all phases of System Development Life Cycle SDLC , I have gained thorough understanding and experience in documentation, requirement elicitation, scope creep, etc. Along with technical ability, I have strengthened my inter-personal skills to be compatible with work environment. I have strong work ethics and analytical skills coupled with good communication and interpersonal skills describing a committed team player. I aim to better myself because I believe in continuous improvement each day every day.

EXPERTISE:

• In-depth knowledge of HIPAA 4010 and 5010 standards for different transactions, PPACA, CAQH CORE, ICD 9/10, HIX, EDI , HL 7, MEDICAID and MEDICARE-part A, B, C and D.
• Extensive knowledge of PPACA Obama Care , HIX, Medical Management Information Systems MMIS , FACETS and National Provider Identifier NPI , Paid without Prejudice concept.
• Extensive experience in Electronic Data Interchange EDI transactions and Codes like: 837 Health care claims , 270/271 Inquiry/response health care benefits , 276/277 Claim-status , 834 Benefit-enrollment , 835 Payment/remittance advice mainly Professional and Institutional Claims.
• Proficient in conducting JAD, JAR, Walkthrough, interviews, Brainstorming sessions with SME's and Stake holders as well as creating meeting minutes and memos.
• Created numerous Business Requirement Documents BRD and converting into Functional/System Requirement Documents FRD/SRD , Test Scripts and Cases.
• Experienced in conducting Impact and Gap Analysis to check the compatibility of the existing system/infrastructure with the new business requirements.
• Created numerous Change Request Documents and Requirement Traceability Matrices RTM and Companion Guides.
• Hands on experience in developing Use Cases and Use case diagrams using Unified Modeling Language UML and process flow Static and Dynamic diagrams like State, Class, Sequence and Activity diagrams.
• Expert in Data Mining, Data mapping, Data modeling and data validation documentation.
• In-depth understanding and experience working with object oriented Relational Database Management System RDBMS , Online Transaction Processing OLTP , Online Analytical Processing OLAP , and Data warehousing concepts.
• Participated in UAT, Integration, Regression, Black Box and White Box testing.
• Defect Management / Bug Fixing Fully involved in the process of defect identification and resolution using tools like Test Director, Clear Quest and Quality Center
• Created numerous Standard Operating Process SOP , User Manuals and conducted training sessions for the users.

TECHNICAL SKILLS:

EXPERIENCE:

Confidential

Senior Business Systems Analyst/ EDI Analyst

ConnectiCare offers a full range of health insurance products including newer ones such as health savings accounts and individual insurance. We continually develop new products to meet the changing demands of consumers, government, and business.

CAQH CORE Compliance

Working on PPACA CAQH CORE project which encompasses 270/271, 276/277 and 835 transactions through Phase I, Phase II and Phase III. The intent of the project is to attain CAQH CORE certification from EDIFECS which is an active testing partner of CMS. This mandate requires all healthcare entities to streamline the EDI transaction processing from system and data content perspectives. My role was to single out all the pertinent CAQH CORE requirements and then have them implemented onto all the impacted system. I have been involved with creating detailed specification documents and various other artifacts to highlight the tasks needed to be performed to implement the CORE rules.

Responsibilities:

• Working with trading partners to finalize the data mapping of the 270/271, 276/277 and 835.
• Coordinating with other Service Providers and creating RTM for the requirement.
• Facilitate and initiate meetings with other Application Service Groups to make sure that all eligibility and benefits are sent with the right deductible to the providers and other trading partners.
• Analyze the gap between the current state and to-be state create Logical diagram for current and future state using MS Visio.
• Extensive use of Business Process Modeling Notations Data flow diagrams to represent the flow of data from external entities into the system.
• Creating test strategy document, finalizing dates for all the test deliverables including System testing and integration testing.
• Work closely with Business and trading partners and drive them through all the Waterfall Phase from Designing, Testing to Release Phase.
• Work with the clearinghouses, and gateway providers to schedule monthly eligible member list.
• Test the environment to have a successful transaction.
• Analyze and document non-functional system requirements.
• Responsible for entering the test cases on HP Quality Center QC .

Environment: MS Office Suite Word, Excel, Power Point, Visio, Project, Access, Share Point , ETL, Agile, BizTalk, Quality Center, SQL, XML.

Confidential

Sr. Business System Analyst

Worked at State of NE Department of Health and Human Services as a Business Analyst, I was involved in multiple projects, primarily focused on ICD-9 to ICD-10 Mapping and Modeling Implementation process, claims processing Medical/Dental , provider and Reimbursement segment. I provided support through the entire lifecycle for multiple projects involving web service and user interface development, covering Provider, Claims and Reimbursement Processing domains. Also the project aimed to extend and expand the Physical Health Managed Care to all counties in the State of Nebraska. As a part of this project, Coventry Cares of Nebraska and Arbor Health Plan were brought in along with the already existing Plan and Managed Care services were provided to all the counties.

Responsibilities:

• Acted as a liaison between Business area Subject Matter Experts SMEs development team throughout all phases of SDLC starting from Inception to Transition phase of the life-cycle.
• Identified AS-IS process flow of ICD-9-CM and ICD-10-PCS compliance requirements using the gap analysis for the existing architecture.
• Updated data processes, data reporting, data collection tools and other processes such as problem lists, writing orders, referrals according to ICD-10 code set.
• Ensured that ICD-9-CM procedure codes used for services and CPT codes were not outdated
• Contributed in ICD-10 Awareness Training Management Plan, created evaluation tool, and survey questions
• Reviewed state documents policies, manuals, business processes, systems documents, banners, bulletins from various divisions. Analyzed and performed quality assurance to determine areas impacted by ICD-9 related data
• Used SQL for back end testing, data retrieval and data analysis.
• Generated numerous Business Requirement Documents Functional requirements specification documents, Use cases, system flow and work flow diagrams.
• Worked with the Managed Care Subject Matter Expert SME and Users to ensure that all the requirements for system change are covered.
• Extracted and refined user requirements by conducting JAD sessions, facilitating meetings interview with Business Units and Technical Supports Development team, identifying the business flows and process flows, conducting detailed and comprehensive business, functional system analysis to determine High Level and Low Level artifacts deliverables.
• Developed business and detailed functional requirements related to changes to be made to the claim entry screens, including Practitioner, Crossover Practitioner, Dental and Hospital Claim Entry Screens.
• Involved in remediation of the legacy MMIS to meet the minimal functionality necessary to electronically send, receive and process the HIPAA compliant standard transactions, and fully implement all components of NPI Compliance.
• Incorporated and updated all MMIS screens for NPI Implementation used for paying claims
• Created new screen layouts and identified locations for new fields being added and existing fields which are being moved.
• Used SQL to query the database for performing data analysis and data
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Developed business and functional requirements for the National Provider Identifier NPI Crosswalk and Crossover Claims Crosswalk solution.
• Developed Test Plans and Test Execution Procedure Document based on the Business Functional Requirement Document and numerous Test Cases and Test Scenarios to cover overall aspect of quality assurance.
• Successfully tested all the test conditions, documented the defects and discussed with technical analysts the discrepancies between expected and actual results for the test conditions.
• Conducted knowledge transfer sessions which were used to make the users and other teams aware of all the changes being made in the system as part of various projects.
• Assisted End User in performing User Acceptance testing and performed testing of the end result files created by the development team to verifying whether all the User Requirements were catered to by the development effort.
• Developed workflows that demonstrate current and proposed business requirements.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: MS Office, SQL Server, MS Project, MS Visio, Unix, J2ee, ETL, Java, XML.

Confidential

Senior Business Systems Analyst

Medica has provided health care coverage to Twin Cities for more than 30 years and one of the leading health care providing companies in MN. Project scope included the conversion of Business and IT processes to be compliant with HIPAA 5010 namely, Invison Acute facilities Signature Professional Offices Proprietary Claim Scrubber - Managed claims processing for the entire enterprise. Also contributed to the early phase of another project aimed to enable readiness of Business and IT processes for the next phase of regulatory change ICD-9 to IDC-10.

Responsibilities:

• Assisted in identifying project scope, to conform to the regulatory compliance related to X12 837 I/P , 835, 834, 270, 271, etc.
• Responsible for soliciting and eliciting requirements for 4010-5010 conversions.
• Involved in building training material and planning material for 4010-5010. Define communication plans and build a project budget for the transition.
• Developed cross-walk for understanding major changes from ICD-9 to ICD-10 versions.
• Carried out Risk Assessment and Impact Analysis for the HIPPA 4010-5010 conversion project.
• Authored Computer Validation Report, which involved extensive research and interaction with SME's and Business owners.
• Involved in one-to-one interview sessions and JAD sessions with stakeholders, SME's and business owners to discuss the scope of the conversion.
• Produced for transaction sets 835 and 837 I/P a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy.
• Involved in up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 by conducting Impact Analysis and Risk Assessment and worked on the mitigation plan to avoid the risks.
• Identified the impact on the existing services of Business Units, local impact of the transition on the organization and forthcoming challenges and issues related to the transition.
• Worked as a liaison among stakeholders both business and IT side in order to elicit, analyze, communicate and validate requirements for changes to business processes.
• Involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Involved in creating Reports and Documents like Requirements Documents, and Management Plan, Issue/Alternatives documents, Project Summary and Plans with formats like PDF, HTML, Excel and Word.
• Prepared UML diagrams Activity diagrams, Sequence Diagrams, Use case diagrams for Extensions and Surrounds.
• Played a key role in project planning activities, User Acceptance testing, and implementation of the system enhancements and conversions.
• Involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions based on the findings.
• Generated various SQL queries and worked on the documentation of the databases.
• Identified the master file changes and builds needed to enable the 5010 format to be utilized.
• Conducted Business Process As Is/To Be sessions with various department directors and staff to ensure the Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program covered all identified new and changed processes.
• Gathered requirements for impacted system and business areas for ICD-10 and their needs to embrace the changes.

Environment: Rational RequisitePro, Rational ClearCase, Facets, Agile, UML, HTML, MS Project, MS Visio, Quality Center, MS Office.

Confidential

Business EDI Analyst

The project focused on Web portal application which gives all the information of the claim and member information. Customer Care Representatives used this application to serve the customers.

Responsibilities:

• Verified various transactions according to HIPAA rules 834 and X12 standards.
• Captured and re-engineered transactions with legacy systems Enrollment-834, Health Plan Premium-820, Eligibility Transaction 270/271 , Claims 837 , Claim Status Report and Response 276/277 , and Remittance 835 .
• Developed functional/technical specifications such as Business Scope Document and High Level Design Document.
• Analyzed and identified issues in claims, encounters and remittance advice process flow.
• Rendered X12 Syntax Integrated Testing, Balancing Testing, Code Testing, Specialty Testing and Trading Partner Specific Testing when environment is upgraded.
• Interacted with developers and documented the functionality process of all the components.
• Performed re-testing in order to verify resolution of defects.
• Created Use Case Diagrams.
• Responsible for meeting or exceeding all defined target goals and milestone dates for the project in order to ensure its overall success.
• Conducted JAD sessions with clients and technical units.
• Conducted GAP and SWOT analysis.
• Performed manual testing and recorded results and used SQL queries for enhancements.
• Followed Agile software development lifecycle during the project.

Environment: Rational RequisitePro, Rational ClearCase, Agile, UML, HTML, MS Project, MS Visio, Quality Center, MS Office.

Confidential

Business Analyst

Project is to develop web-based application developed for the business customers of the Gulfstream Property Casualty Insurance Company. The company offers various products for the business customers like Property, Liability, Business Income, Workers Compensation, Commercial Automobile and Commercial Umbrella. The customers can manage their insurance accounts, pay premiums, file claims etc. online using this application.

Responsibilities:

• Analyzed clients systems and business processes.
• Managed General Liability, Commercial Property, Commercial Package, Commercial Auto and Workers Compensation policy lines
• Provide support across different domain areas such as Auto Assignment, Payments, Claims Documentation, and Appointment Logs, Auto Estimations, Fire Claims etc.
• Analyzed the business rules for Auto claim assignments throughout the US, so as to have balanced work load for all the claims reps.
• Developed a file of ACORD Forms used as the standards in all Property and Casualty markets, for both Personal and Commercial Lines of Business.
• Responsible for testing the Quote Online Purchase for both Auto and Home Property Insurance of the customers.
• Analyzed standard industry practices of back office applications of Insurance Company, underwriting, billing, policy and claims administration with the help of Subject Matter Expert.
• Worked on an application that took care of online account services which included Bill paying, checking the bill history, changing customer profile, ordering auto insurance ID cards Worked on Commercial lines Property and Casualty Insurance including both policy and claim processing and reinsurance.
• Used SDLC System Development Life Cycle methodologies like the RUP and the waterfall.
• Worked extensively with MS Excel and MS access
• Performed Requirement Analysis to Develop Use Cases, Activity Diagrams and Sequence Diagrams. Hence developed and documented conceptual design of Application in System Specification Document.
• Integrated Rational Requisite Pro with Rational Rose, Clear Quest and Clear Case to provide the visibility to the teams and maintain traceability among Requirements, Use Cases, Change requests and Configuration Changes.
• Data mapping, logical data modelling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Wrote Test plan and Test cases for the Integration testing and system testing.
• Designed the business requirement collection approach based on the project scope and SDLC Methodology.
• Clarified QA team issues and reviewed test plans and test scripts developed by QA team to make sure that all requirements will be covered in scripts and tested properly.
• Conducted JAD sessions for communicating with Stakeholders and Project directors.

Environment: Mainframes, COBOL, .NET, Agile, JCL, Db2, XML, Quality Center, Oracle, Rose, MS Word, MS PowerPoint, MS Excel, MS Visio.

Confidential

Business Analyst

The project was regarding the Electronic Medical Claim Software System that facilitates providers to send electronic claims in short time, and thereby ultimately increase the revenue cycle efficiency. The primary feature of the software included Electronic verification of insurance eligibility, Electronic claims status inquiry, Financial Ledger, Essential system reports and automated reminders. The system's goals were to maximize the value of online health information expand utilization of programs, services and products.

Responsibilities:

• Writing the detailed user needs, Gathered requirements during inception phase, Documented and Delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD Object Oriented Design using UML and Visio.
• Identified, researched, investigated, analyzed, defined and documented business process and Use Case scenarios.
• Conduct workflow, process diagram and GAP analysis to derive requirements for existing systems enhancements.
• Worked on insurance data related to Medicare, Medicaid, and Insurance claims.
• Worked on HL7 to provide framework to carry out transfer of electronic healthcare information.
• Helped manage risk analysis and mitigation plans, status reports, and client presentations prepared business process models, defined milestone deliverables, and established critical success factors.
• Functioned as the primary liaison between the business line, operations, and the technical areas throughout the project cycle.
• Formulating the systems of project to parallel the business strategies.
• Analyzed research on operational procedures and methods and recommended changes for improvement with an emphasis on automation and efficiency.
• Wrote SQL queries in MS Access for data manipulations.
• Assist with user testing of systems, developing and maintaining quality procedures, and ensuring that appropriate documentation is in place.
• Develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Used Test Director with QA team for testing.
• Interfaced with SME's to prepare BPR documents for ongoing projects.

Environment: RUP, MS Project, ANSI X12 EDI, Rational Rose, HP Service Desk, MS Visio, MS Word, MS Excel, Medicare, Medicaid, Rational Requisite Pro, ETL, SQL.