SUMMARY

• Over 7+ years of extensive experience in Business Analysis, specifically within Healthcare Industry.
• Strong knowledge of Healthcare industry including HIPAA, EDI with emphasis on Business Requirements and Functional Requirements.
• In depth knowledge of Software Development Life Cycle(SDLC), having thorough understanding of various phases like Requirements Gathering, Analysis/Design, Testing and Waterfall Model and Agile Software Development Model.
• Extensive experience in translating clients’ policies and business rules into understandable concepts for use case and business requirement creation.
• Worked closely with customers to implement capacity management solution for the medical management group. Solution included Medicare, Medicaid and Commercial lines of business.
• Experience in using Facets support systems to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• 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 Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• In depth knowledge of health care basics including Medicare/Medicaid (Part A, B, C and D) HIPAA 4010-5010, ICD9 and ICD10 and EDI Transactions.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 utilizing the ICD-10 codes.
• Proposed strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Facilitate integration and applied ANSI ASC X12 standards for 810, 837 (P, I, D), 850, 855, 270/271, 276/277, 278, and 835 transactions.
• Extensive experience working on business process development and maps for 810, 850, 855 and 856 transactions.
• Expert in designing future state processes for transaction processing EDI's 810,837,835,856,855,850 270, and 271.
• Transactions and performed gap analysis between the 4010 and 5010, proposed strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Responsible for Gap analysis in HIPAA 4010 to HIPAA 5010.Incorporated and implemented all the HIPAA standards, Electronic Data Interchange (EDI), transaction syntax like ANSI X12, ICD-9, ICD-10 coding.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 codes.
• Expertise in Rational Unified Process (RUP) Best Practices methodology, Use Cases, Software Development Life Cycle (SDLC) processes and Object Oriented Design Technologies.
• Experience in creating Test Plans, build Test Conditions and Test Cases, creating test data, analyzing bugs, interacting with development team members to fix errors.
• Led teams across broad technical and business disciplines.
• Strong communication, problem solving, organizational, interpersonal, and presentation skills.

TECHNICAL SKILLS

Business / Modeling Tools: MS Project, MS Visio, MS Excel, MS Word, MS PowerPoint, Rational Ros

Databases: MS Access, Oracle (ETL), SQL Server, CDI

Requirements Management Tools: Rational Requisite Pro, Door, Dashboards, Microsoft SharePoint.

Change Management Tools: Rational Clear Quest, Rational Clear case

Scripting Languages: HTML, UML, XML, VB Script

Operating Systems: MS-DOS, Windows 95/98/2k/NT/XP

Web Technologies: ASP.NET, Dream weaver, VB.net and VB Script.

Processes/Technologies: Rational Unified Process (RUP), Use Cases, Workflow

Testing Tools: Load Runner, Quality center, Test Director

Healthcare: EDI, ASCII X12, HIPAA

Project Management: SDLC models, RAD, JAD, Project Scheduling, Cost and Estimation, Requirement and Business Analysis, QA

PROFESSIONAL EXPERIENCE

Confidential, Baltimore, MD

Sr. Business Analyst

Responsibilities:

• Extensively involved in conversion of ICD-9 CM and PCS codes to ICD-10 (Clinical Modification and Procedure Coding System) codes and conversion of all EDI HIPAA X12N-4010 transactions to HIPAA X12N-5010 version and prepare necessary supporting mapping/crosswalk documents as part of project deliverables.
• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Conducted complex documentation and user needs analysis. Interface with team and staff to develop HL7 integration.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Developed the strategy for developing and implementing new EDI (HL7 and X12) interfaces and converting historical clinical and data.
• Designed a claim processing system for the Enterprise healthcare management (EHCM) client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms (ICD-10 codes), and treatment (CPT).
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Developed and implemented the MMIS Third Party Liability (TPL) Subsystem.
• Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, and Medical policy waves.
• Conducted business-impact assessment and the results were compared with the new HIPAA 5010 standards to determine the current level of compliance and developed an action plan for approval by the project steering committee.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD 10Code set andANSI X12 5010formats.
• Involved in gap analysis and implementation of HIPAA 5010, ICD 10 and Claim Validations.
• Conducted Gap Analysis, and Gathered User Requirements by Interviews, user meeting, JAD session, and Requirement Elicitation Sessions.
• Worked on CRM (Customer Relationship Management) project to implement Microsoft Dynamics.
• Worked with the Marketing Management/team members to understanding their needs and requirements in regards to picking the right CRM system.
• Part of the project management team responsible for SWOT analysis.
• Used Scrum Work Pro and Microsoft Office software to perform required job functions and prepare Product back log and sprint back log and conduct all the meetings and discuss and help scrum master.
• Responsible for cost estimation and timelines for various Business Intelligence reports.
• Involved in analyzing activities for a variety of major projects including Medicare Plan part D, Coordination of Benefits, New Client Implementations, Consumer driven and regularly scheduled system upgrades.
• Used UML and OO discovery methods to perform discovery for new enterprise wide installation of Trizetto FACETS (both core and extension requirements) using Rational Rose.
• Implemented a mechanism to in corporate business-required data which is not in the core Facets system.NFE (Non-Facets Elements) proved to be of major business importance in implementing state-customizations and underwriting, needs not encompassed by the Facets system.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Assisted to develop the Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge.
• Prepared graphical depictions of User stories, 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.

Environment: HL7, Microsoft Office, SharePoint 2007, EA, MS Dynamics CRM, Cognos, Agile, Rational Requisite Pro, MS Office, SQL Server 2008, Cobol, DB2, MS Project, MS FrontPage, MS Access, FACETS,EDI, Windows 7.

Confidential, Kalamazoo, MI

Business Analyst

Responsibilities:

• Analyzed the Business Requirements and Functional Requirements and Responsible for analysis meetings with business team and development team.
• Analyzed and documented MMIS Claims business rules, edit rules, audit rules, to create and process unit and string test cases to verify and validate updated programs.
• Process inbound and outbound EDI transactions for 850,810,856,832,940 and 945 data.
• Wrote test scenarios and determined preconditions for preparation of test data files. Created, managed and executed test cases, and testing for processing of Medicaid Claims.
• Conducted workflow analysis, data analysis and gap analysis of legacy and EHR/EMR (Electronic Health Record) system.
• Responsible for converting the submitted 837I claims from 4010 manually.
• Expertise in HIPAA, 820,835, 837, 4010, 5010, 997 EDI. Responsible for testing HIPAA EDI Transactions and mainly focused on PA and Eligibility Transactions.
• Active involvement in preparation of test data files and responsible for assisting team members in mocking data according to requirements and analysis.
• Maintain, update, manipulate and create queries in Teradata SQL and Business Objects to pull data from the Enterprise Data Warehouse for reporting Build tables from Teradata SQL/Business Objects queries for SSRS/SSIS/ACCESS delivery.
• Performed portal testing for 837I/P for different lines of businesses using various payer codes and service lines.
• Assisted the Team Lead with daily QA tasks, attended project meetings, release meetings, and QA status meetings.
• Participated in walkthroughs for the evaluation of the test plan with the QA Lead and design & development team.
• Extensively Responsible for daily status meetings and interaction with Business Analysis and Development team to ensure smoothness in progress of the project.
• Performed System Testing and Integration Testing & Functionality Testing of the application. Responsible for entering, Tracking bugs in Quality Center/ALM and reporting the defects to the developers for Modification Request.
• Maintained EDI Maps with the specified business rules. HIPAA map transactions: 837P v4010/5010 Health Care Claim, 276/277 v4010/5010 Claim Status Request/Acknowledgement, 270/271 v4010/5010 Eligibility Coverage, 277U v4010/5010.
• Customized and developed software applications/programs for electronic claims translation/transmission, remittance advice, eligibility and bank transactions.
• Trained staff and ensured all application were HIPAA compliant. Led many HIPAA conversion projects, facilitated meetings and provided the highest levels of quality, professionalism and customer support
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Served as conduit for managing system requirements between the business and the software development team.
• Evaluated testing results for each potential release build using Test Director, Quality Center and reports, listing summarized bug information in priority sequence, recommended viability of release for production.
• Communicated and coordinated collaboration between business functions throughout the lifecycle of a project including human resources, finance, technology, customer relations, and internal marketing.
• Exhibited expertise in technical writing contributing to the development of project design and operational documentation while monitoring and controlling all deliverables by established quality standards.

Environment: HIPAA, EDI, IBM Mainframe, HP Quality Center, UNIX, DB2, Oracle, Facets.

Confidential

Business Analyst

Responsibilities:

• Created Use Cases for functional requirements based on the client’s template.
• Worked with Project Management to scope the testing effort and provided status and estimates.
• Actively involved in UI specs and wireframe meetings to ensure consistency with client’s requirements.
• Developed detailed test plans and test cases, Entrance and Exit criteria for the application being tested and ensured that standards for documentation were followed based on the JAD sessions with the client.
• Responsible for creating Cost Benefit Analysis for the release of the project.
• HIPAA 4010 - 5010Conversion Analysis - Involved in the documentation of HIPAA 5010 changes toEDI837, 834, 835, 276, 277Transactions.
• Performedgap analysisfor HIPAA 4010 837P and 835transactionsand HIPAA 5010 837P and 835transactions.
• Creating Mapping documents fortranslating 837(I/P) to internal XML format and vice versa.
• CompletedData Mappingfor Group and detailProduct analysisandreport writing.
• DevelopedData MappingandCrosswalk documents.
• Involved inclaim adjudication process.
• Identified and fixed edit and mapping issues in the cross paths (4010-5010/5010-4010 ).
• Interaction with the payers and submitters for 5010 UAT certification.
• Analyzed payer/submitter specific 4010 claims editing to migrate it to 5010 claim editing system Identify and document transition issues from 4010 to 5010 format.
• Helpedtestersto createTest scenariosandtest casesfor testing the migration ofEDI4010 to 5010and the processing of member enrollment and benefits, batch jobs corresponding to theclaims (837)and real time transactions like 270/ 271/ 276/ 277.

Environment: FACETS, Payer Solutions, EAI/TIBCO Servers, HP Gateway, Toad for Oracle, SOAP UI, iGATE, HP Quality Center.

Confidential, NE

Business Analyst

Responsibilities:

• Played pivotal role in eliciting requirements and updated Scope, BRD and FRD.
• Conducted the gap analysis for 4010 to 5010 HIPAA EDI Transactions.
• Managed requirements using Rational RequisitePro.
• Worked with Agile-Scrum Master to translate HIPAA requirements for HIPAAHL7 Conversion project created Interface specification during requirement sprints and update Cross-X Walk documents.
• Experience in negotiating conflicting QNXT requirements during change control process while Implementing Medicare (Part D) Claims.
• Coordinated Requirements Workshops to lock down the Dual eligible Medicare (Part-D) and Medicaid business requirements.
• Documented current business processes, business flows, rules and artifacts, and propose "To-Be/Future” business processes Medicaid and Medicare Pharmacy benefit project.
• Facilitated JAD session for altering custom HIPAA -EDI270/271(Benefit and Eligibility Inquire/Response) & 837 EDI process flows.
• Translated the Functional Requirements into use cases and use case diagrams.
• Worked with Architect, SME and Developer to enhance “AS-IS” the process diagram using MS Visio.
• Extensive experience with Claims processing on NASCO, FACET4.7.1 claims for migrated members
• Updated Requirement Traceability matrix and worked with Developer to bring in Change control PVRC Tracker for deployed code. Effectively managed version and change control during the migration from NASCO to FACETS.
• Facilitated weekly status meeting and created weekly status reports on progress of key team efforts.

Environment: Agile-SCRUM,QNXT, UML, NASCO, Rational Requisite Pro, MS VISIO, PVCS Tracker and MS OFFICE (Word, Excel, MS Access, PowerPoint).

Confidential

Business Analyst

Responsibilities:

• Healthcare business analysis, bridging clients and software development team.
• Translated business requirements into functional requirements and approaches for developers.
• Involvement in full Healthcare System Development Life Cycle with understanding of a variety of technologies and platforms such as web, client/server, relational database concepts and object-oriented programming.
• Represented the organization in client meetings, document meeting outcomes, and Co-Ordinated all internal and external follow-ups to close issues in support of the project requirements.
• Workflow documentation and comprehensive training to the healthcare clients.
• Analyzed corporate healthcare business processes to develop customized solutions.
• Worked as a functional and technical analyst to support healthcare client\'s system.
• Healthcare client interaction to gather requirements, objectives, input and output requirements.

Environment: MS Project, Visio, MS- excels, MS Access, Rational Test Manager, Rational Requisite Pro, Rational Clear Case, Clear Quest, Rational Rose.

Confidential

Business Analyst

Responsibilities:

• Involved in implementation of HIPAA EDI Transactions (835,837).
• Facilitated Electronic Data Interchange.
• Performed GAP Analysis for HIPAA 4010 and 5010 transactions.
• Recommend changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Analyze HIPAA EDI transactions in X12 responses and of 837, 835, 277CA and 999 and looked for defects.
• Do data analysis for various version changes of EDI messages on different sub-systems.
• Providing the required test data for the developers in order to fix the defects.
• Participating in QA team meeting and bug tracking meetings.

Environment: UNIX, MS Power Point, MS Excel, MS Visio, Rational Rose, System Analysis, SQL.