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Sr. Healthcare Business Analyst Resume

Tampa, FL


  • With 7+ years of IT and Management experience in Software Development Life Cycle (SDLC) and Project Life Cycle working as Business Analyst mainly in Healthcare sector.
  • Well Familiar with current industry standards, such as HIPAA, SOX, ISO, Six Sigma, and Capability Maturity Model (CMM).
  • Strong experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, and Insurance Claims.
  • Strong knowledge of software development life cycle (SDLC), waterfall, Agile/Scrum, and RUP (Rational Unified Process).
  • Proficient in HP Quality Center, WinRunner, QuickTest Pro, Business Objects and Manual Testing.
  • Experience in using HP Quality Center for maintaining, executing test cases and defect management.
  • Oversees the execution and completion of information technology solutions projects for the Healthcare/Payer Solutions area.
  • Functional experience in Health Care Industry with in depth knowledge on Medicare and Medicaid Part A, B, C & D, PPO, POS, and HMO health insurance plans, EMTALA, CMS.
  • Strong knowledge of managed care Payer requirements and procedures.
  • Strong experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.
  • 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).
  • Experience in writing test plans, reviewing test cases and mentoring QA teams.
  • Good exposure to various healthcare Payer systems for Claim processing.
  • Excellent communication and presentation skills, self-starter, quick learner, team player.
  • Worked with Software Development Life Cycle (SDLC) including Feasibility Study/Gathering Requirements, Analysis, Design, Development, Testing, User Acceptance Testing (UAT), Implementation and Postimplementation Validation.
  • Performed data validation using SQL Scripts for various business scenarios.
  • Good experience with Rational Rose, Rational Requite Pro, Rational ClearQuest, Rational Clear Case, MS Project, MS Visio.
  • Excellent meetings facilitator with excellent inter-personal and conflict resolving skills.
  • Proven success as a business analyst through the years, providing a well-balanced understanding of business relationships, business requirements, and technical solutions.


Methodologies: Waterfall, RUP, Agile SCRUM.

Tools: MS Office (Word, Excel, Project, Visio, etc.), Rational Rose, Requisite-Pro, Clear case.

Testing tools: JIRA, RALLY, HP Quality Center, Quick test pro

Languages: SQL, UML, HTML

Operating system: Windows XP, UNIX

Databases: MS-SQL Server, MS Access, Vertica

Industry Standards: HIPAA 5010, ICD 10, PPACA (Patient Protection and Affordable Care Act)


Confidential - Tampa, FL

Sr. Healthcare Business Analyst


  • Played an active and lead role in gathering, analyzing, and writing business requirements.
  • Project was implemented in phases, enabling system to deliver as many business requirements as early as possible.
  • Involved in Requirement Scoping and analysis of high priority requirements for implementation.
  • Worked on Transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
  • Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
  • Evaluated Medicare requirements and benefits in Medicare Health Plans for member enrollment and management.
  • Coordinated, implemented and provided on-going support of the Quality Performer as outlined in the Specifications Manual for Well Care Inpatient Quality Measures Centers for Medicare & Medicaid Services (CMS).
  • Used HP Quality Center for writing Test plans and Test Cases.
  • Worked on documenting business rules to be defined in the business rules management engine (IBM ODM).
  • Participated in requirements meetings, writing requirements in CaliberRM, converting requirements from Caliber RM to HP Quality Center.
  • Working knowledge of implementing software development projects using methodologies such as Waterfall, RUP, and Agile Scrum.
  • Used HIPAA guidelines and regulations to keep track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.
  • Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project. Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
  • Developed Software Requirement Specification (SRS) document using Visio and MS Office.
  • Loaded the defects on to HP Quality Center and maintained a track record of the updates on the defects from the development team.
  • Executed Test Cases Manually, once the application is stable and documented the successful or unsuccessful completion of each test case in HP Quality Center (QC) for End-to-End Scenario based testing.
  • Worked on Agile SDLC during the project phase, performed the role of Product Owner and Team member in Scrum Meetings.
  • Participated in agile process - planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iteration.
  • Involved in Testing Out-Bound Transactions (835 Health care claims Payment, 277 Claim Status Response).
  • Consulted with healthcare third-party administrator company to develop conversion specifications for member, enrollment, and authorizations.
  • Involved in Scrum development process and prepared Sprint burn down chart, product catalog and sprint backlog contain Business Requirements and supporting documents that contain the essential business elements and definitions as well as the tasks to be completed.
  • Tested and validated Identity Management CITT implementation as it pertains to the upgrade to CARE and EDI enrollment systems.
  • Responded to billing inquiries from patients and payers.
  • Attended various government payer conferences, reporting back all new federal/ state mandated billing laws or changes.
  • Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/ Advice).
  • Authored Companion Guide to support all the information needed to process HIPPA transactions with Well Care Group.
  • Prepared user acceptance criterion and testing strategy that will be utilized by QA team to validate the addressed functionality of all critical requirements. Developed and maintained Test Matrix and Traceability Matrix. Utilized Quality Center to plan and execute tests, track defects and create change alerts. Conducted User Acceptance Testing (UAT)

Environment: HIPPA ANSI X12, SDLC, .Net, CPT and ICD-9 Coding, Rational Rose, Rational Requisite Pro, Microsoft Visio, SAS, Java, MS word, MS Excel, MS outlook, MS Access, XML, HTML EDI, MS SQL Server.

Confidential - Dublin, OH

Business Analyst


  • Worked on changes for HIPAA Transaction and proposed changes to be made in the current system for an easy transition from version 4010 to 5010.
  • Led and managed the software requirements and design activities for a Centers for Medicare & Medicaid Services (CMS), analyzing existing business processes, suggesting "To-Be" business processes, and recommending alternative business and technical strategies.
  • Conducted Joint Application Development (JAD) process with Stakeholders to analyze deliverables and system constraints.
  • Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicare/Medicaid Claims.
  • Utilized corporation developed Agile SDLC methodology. Used Scrum Work Pro and Microsoft Office software to perform required job functions.
  • Worked on transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
  • Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
  • Performed all test cases consisting with team members in-house and remote offices, vendors, clearinghouse, state governments, satellite offices, and financial institutions using HP Quality Center Enterprise Edition / Mercury Test Director.
  • Monitor the Change Management process for infrastructure or technology changes that would impact Disaster Recovery.
  • Led the requirements gathering, design, and project planning activities for CMS and acted as a liaison between developers, testers and stakeholders regarding requirements, defects, and issues.
  • Performed Gap analysis for better understanding of transition from HIPAA 4010 to HIPAA 5010.
  • Identified high level CMS part D requirements and submitted to PM for CMS Audit purpose and presented that to the management team.
  • Used HP Quality Center for creating test cases and created Business component for shakeout scripts.
  • Used HP Quality Center for test scripts creation, execution, test coverage and defect tracking.
  • As a Business Analyst initiated to build and modify the application to Edit and Scrub the Medicare Part D Prescription Drug Event (PDE) data coming into the process from different sources before Regence can send it to Centers for Medicare & Medicaid Services (CMS) for reconciliation so that the error rate can be reduced.
  • Collaborated with CMS program and technical staff to review proposed program definition/ruling and provided recommendations to program design and high-level risks and/or impacts.
  • Was initiated to incorporate the CMS mandated change of adding few new fields into the Medicare Part D - Prescription Drug Event Claim Data and all the system it passes through within Regence.
  • As a Business Analyst involved in overall program management of the Health Care Financing Administration (HCFA/CMS).
  • Analyzing Medicaid claim data and financial data as well as reviewing applications for completeness to process applicants for Federal Medicaid Program.
  • Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan).
  • Defined the test criteria, project schedules and base lined the Test Plan with the help of project meetings and walkthroughs.
  • Performed extensive Regression testing on Claims supported simulated system.
  • Analyzed the existing claims process and specific business rule logic will be applied in the requirement model.
  • Conducted UAT to confirm that all derivative products can be successfully processed through stages of the trade life cycle.
  • Performed GAP analysis to identify AS-IS a process EDI transaction set 834, 837 and 835 of 4010A and TOBE processes of 5010 standard and based on that developed Business Requirement Documents.
  • Working with clients to better understand their needs and present solutions using structured SCRUM approach.
  • 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).
  • Worked with QA team from the planning phase to create the Test strategy and Test plan for available Test document from CMS (Center for Medicare and Medicaid Services) • Worked with Source System Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
  • Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
  • Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
  • Prepared Test cases (using test data available from CMS test document) during Design phase with presence of QA team and implemented plan for integration and functional testing.
  • Assisted with user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
  • Integrated Requisite Pro with Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.

Environment: SQL Server, .NET, Windows 7, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, Java, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML

Confidential - Baton Rouge, LA

Business Analyst


  • Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
  • Coordinated with the stakeholders and project key personnel to gather functional and non-functional requirements during JAD sessions.
  • Studied the existing business process and created AS-IS workflow to illustrate the existing system.
  • Assisting the project manager in creating the business case and project plan.
  • Client liaison with CFO's and CEO's of hospitals as well as Government agencies such as CMS and DHH.
  • In Depth knowledge of Medicaid Claims processes from Provider/Payer side which later became training program to vendors.
  • Responsible for Medicaid Claims Resolution/Reimbursement for state health plans using MMIS.
  • Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
  • Defects and bug testing by using Rational Clear-Quest, Configuration management and Version control with Clear-Case.
  • Responsible for creating business work flows and processes and creating management reports based on the analysis.
  • Followed the UML based methods using Rational rose to create use cases, activity diagram, sequence diagram, collaboration diagram that include functional and non-functional specifications to hand off to development teams.
  • Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
  • Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.

Environment: MS Project, ANSI X12- EDI, XML, HTML, JAD, .Net, Rational Requisite Pro, MS Word, Sharepoint, Visio, SQL, MS Excel, Java, Mercury Quality Center.

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