SUMMARY

• Over Eight years of Experience as a Business Analyst/Validation Analyst in Health Care, Insurance and Pharmaceuticals.
• Experience in full life cycle of system development, from requirements gathering and business case development to roll out and maintenance.
• Involved in Software development processes using SDLC, RUP and RAD and proficient in applying RUP in all the four phases of development.
• Good understanding of Rational Unified process and have expertise in using Rational suite products like Requisite pro for requirements management, Clear quest for the change Management, Test suite for Testing.
• Good Expertise in using the Caliber RM in daily requirement analysis including Creating and editing requirements, Tracing to other objects, Creating reports and specifications.
• Extensive experience in UML diagrams (sequence diagrams, Activity diagrams, class diagrams) and writing Use cases, Business process, work flows, process flows using Microsoft Visio and Rational Rose.
• Worked on Trizetto Facets 4.61 and 4.71. Worked on different modules like Provider, Payer and claims in Facets.
• Hands on experience in Claims Test Pro of Facets.
• Excellent experience in gathering requirements by conducting ( Joint Application Development) JAD sessions, interviews and questionnaires and converting them in to Business requirement documents(BRD)/ Functional requirement documents(FRD), Non - Functional Requirements(NFRD) and in performing GAP analysis.
• Involved in developing QA strategies: test plans, test cases and Knowledge in using QTP, Test Director, Win Runner, Load Runner, Team Track, and executed the system testing and User Acceptance testing.
• Good Knowledge of using SQL and PL/SQL to access databases (Oracle, Sybase) and Good working experience on Java Application and Java Portal on the Front end and on the Developers Interface.
• Hands one experience working on NASCO platform.
• Good Knowledge of Clinical trials of Experimental Drugs on Human and animal Subjects, done in Different Phases ( especially Phase I ), following the FDA Regulations and Drug Safety Protocol and followed the Federal and HIPAA regulations in exchanging the data electronically, securely with ease.
• Good Understanding of the HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Inbound and out Bound transactions from various Health care Providers ( Trading Partners ) and CMS.
• Worked on NCPDP 5.1.
• Good Knowledge of Implementation of NPI (National Provider Identifier) number for the Health Care Provider for implementation of HIPAA guidelines and in following the ICD-10 Code Sets for filing the claims by using the CMS-1500 forms.
• Experience with insurance claims processing using main frame legacy system (on oracle, SQL background) and paper intensive environment and expertise in using facets reporting Management tool for the membership eligibility, billing, claims processing and claims reporting..
• Good knowledge of Epidemiology and Biostatics for analysis of data and Data management using SAS and SPSS tools for clinical trials.
• Knowledge of managed care concepts (Medicaid and Medicare), US health care regulations and practices.
• Excellent written, verbal and interpersonal skills.

TECHNICAL SKILLS

Languages: C, C++, Visual BasicCASE Tools Rational RequisitePro, Rational Rose, ClearQuest, Test Suite, Caliber RM

Workflow Tool: MS-Visio, MS ExcelSQA Tools LoadRunner, WinRunner, TestDirector, QuickTestPro, Quality Center.

Databases: Oracle, MS Access, SQL Server

Other tools: MS-Project, MSOffice, SAS, SPSS, Facets Management Tool, HTML, MEGA

Standards & Methodologies: SDLC, RUP, HIPAA EDI, HL7, e-CRF, CPT & ICD-10 Coding, CMS and CFR

PROFESSIONAL EXPERIENCE

Confidential, Pittsburgh, PA

Business Analyst

Responsibilities:

• Responsible to insure that EDI Process is HIPAA (Health Insurance portability and Accountability) compliant and worked on ANSI X12 standards.
• Coordinated collection of business needs. Involved in converting high level requirements to functional requirements and documented them in functional, navigational and page Use Cases. Prepared Functional Requirements documents using the existing templates. Documented business rules and functional requirements iteratively. Imported these use cases into Requisite pro; tagged and traced them.
• Worked on NPI registry to search for provider information for creating the provider directory.
• Involved in performing testing on HL7 messages based on the requirements provided.
• Created HL7 Reference Guides for Version 2.2 and Version 2.5 messages
• Identified the scenarios based on business requirement and HIPAA compliance for each transaction such as 837(Claim) and 276/277 (Claim Status).
• Gathered business requirements through JAD sessions and one-on-one interviews with the Business Stakeholders
• Ensured all EHR, HL7 requirements are met and client is receiving the full benefit of Interfaces.
• Involved in HIPAA 5010 Gap Analysis for ANSI ASC X12.
• Experience in developing business requirements for 5010 EDI transactions.
• Worked on ICD 9-ICD 10 code sets.
• Performed impact analysis and gap analysis for ICD 10.
• Created class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives
• Hands on experience working on Claim Test Pro of Facets.
• Used Claims Test Pro for processing claims.
• Worked on Claims Test Pro of Facets for project tracking and for reporting progress.
• Created and maintained improvement matrix which was subjected to discussion among the steering committee members for post application deployment in production
• Worked with the technical Lead for NPI team for cross walking to unique provider ID's, for all HIPAA transactions
• Prepared work plans for NPI Business Readiness to support the implementation of the Federally Mandated HIPAA NPI (National Provider Identification) initiative.
• Defined NPI Crosswalk table to identify BCBSPA providers & their new NPI to receive their electronic claims (837) and to send their electronic payments (835).
• Generated activity diagrams and Developed design specific constraints such as interface type or security level using optimal trace.
• Worked on billing and payments in the provider module in Claims Test Pro of Facets.
• Involved in performing Functional, Integration and UAT testing.
• Used Mercury Quality Center for Test Cases, Test Run and Defect Tracking
• Participated in test plan development, performing tests, reviewing results, and logging defects.
• Developed all operational and technical flows using MS Visio and involved in the creation of Business Architecture Document to provide an overview of different aspects of the application.
• Performed data analysis and converted member IDs (PID) to alternate member IDs for all of the MS Access databases used by Claims system.
• Processed Medicare claims and Worked on EHR as a web based application.
• Performed Data mapping, logical data modeling.
• Used SQL queries to filter data within the database tables.
• Involved in Data Selection for testing the EDI Load Process: backend process for loading and processing the data received through EDI and manual process as per Business Rules.
• Preparation of Traceability matrix.
• Participated in Testing using SQL queries on SQL Server tables and generating reports to ensure data integrity.
• Performed UAT testing with client and supported all phases of testing with QA team and managers
• Facilitated and co-coordinated all User Acceptance Testing activities.

Environment: MS Visio, MS Project, Test Foundation Server (TFS), Windows XP, HL7 2.2, 2.5 and 3, Microsoft Office suite, Microsoft Visio, Test Director, Rational Unified Process (RUP), Clear Case, UML, Microsoft Project, Rational Rose

Confidential, Franklin, TN

Business Analyst

Responsibilities:

• Assembled business requirement documents (BRD) and the functional specifications as per the user requirements.
• Worked on FACETS 4.71
• Prepared FSD for 5010 from 4010A
• Created Business Workflow based on the requirements gathered from the client.
• Created functional specification documents based on the business requirement documents.
• Conducted weekly meetings with the clients and internal teams to formulate priorities and determine solutions both automated and manual.
• Involved in standardizing the documents to meet the HIPAA Compliance Standards
• Management according to the HIPAA Compliance Standards for Claims Processing.
• Extensively worked with HIPAA 837,834,835,297 files.
• Working knowledge for Facts Batch job.
• Extensively worked with HIPAA Privacy Facets application groups
• Wrote complex SQL queries to extract and validate the data from the Facets database
• Involved in creating documents and diagrams for Claims Processing.
• Extensive Knowledge and experience in EDI transactions, ASC X12 Transactions like 270,271,277.
• Have gathered requirements in compliance with HIPAA, Knowledge of HIPAA 4010 and 5010 transaction standards.
• Gathered requirement documents for transition from ICD-9 to ICD-10.
• Worked on modules related to Claims, Providers, & Contracts and worked with Claims attributes, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in FACETS.
• Analyzed the FACETS (claims engine) data and discussed with the Business team regarding the Requirement.
• Working Knowledge of the data model, data fields, relationships (backend) of the FACETS System. FACETS tables such as Provider, Contract, Benefit, Claim, Claim details, and Member.
• Performed UAT on 5010 and ICD10 codes.
• Organized JAD Sessions to resolve issues and conflicts, and to arrive at quick agreements regarding the system architecture design.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.
• Analyzed and documented the limitations of the billing system.
• Interacted extensively with the client and the management teams to understand the requirements and to report the status of the testing efforts on their applications.
• Extracted the data from meta data (database data-dictionary, mapping tools etc.)Conducted individual and group joint application development (JAD) sessions with business stakeholders and technical units. Identified BASEL data requirements and produced data mapping.
• Performed Gap Analysis. Followed the RUP methodology for the entire SDLC. Actively worked with developers as needed to isolate the Root Cause Analysis of defects.
• Worked with the clients on the final signing process in the User Acceptance stages. Managed scope and deadlines.
• Participated in various meetings and discussed enhancement and modification request issues.

Confidential, Owings Mills, MD

Business System Analyst

Responsibilities:

• Engaged in different phases of SDLC of the project executing RUP methodology of iterative software development from Inception to Transition phase.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Created different documentations based on CMMI standard model.
• Conducted detailed and comprehensive business analysis by constantly working with the Business Users, Solution Engineers, Developers and Testers, Management, Deployment and Support Staff in order to determine High Level and Low Level artifacts & deliverables to be produced and design the application that will support the business and meet the constraints of time, resources and budget.
• Acted as liaison between development team, testing team and Business SMEs to generate and standardize Functional requirements specification documents, Use cases, Vendor Specification documents and Architectural documents. Converted Business requirements into Functional requirements so that designers and developers can understand.
• Also performed the Data Analysis and Data Mapping for different source system including Mainframe system, Data Warehouse and Database to target system, database and application for the Medicare Part D - Prescription Drug claims.
• Employed UML methodology in creating Use Case diagrams, business/process flow diagrams, and Activity/State diagram to assist development and engineering in understanding the requirements.
• Involved in Gap analysis of processes As-Is and To-Be Processes within the organization for implementation of RUP methodologies.
• Worked on NASCO claims processing system.
• Worked on HIHK, EEC, GENO Tables and Benefit file Grid of NASCO platform.
• Assisted development team with design and testing efforts and assisted them on resolving the reported bugs and various technical issues.
• Developed customized SQL reports and queries for management decision-making and operational management.
• Assisted in preparing and executing Test Cases, and reviewed Test Execution Procedure Document (EPD) document prepared based on the Business Requirement Specifications (URS), Functional Requirement Specifications (FRS) to cover overall quality assurance.
• Participated in the team meetings to discuss the issues arising out of testing. Reported weekly and monthly project status updates to project manager and senior management.

Confidential, IL

Business Analyst

Responsibilities:

• Analyzed, documented and managed all project requirements and changes to requirements throughout the software development life cycle through Rational / Telelogic Doors.
• Worked on HIPPA Transactions 270, 271, 276, 277, 834, 835 and 997.
• Analyzed customer needs and existing functions in the area of HIPAA transactions to determine feasibility and requirements.
• Participated in HL7 interface testing in 275 transaction set of claims processing under HIPAA 4010
• Documented Functional/Technical data flow of 4010 HIPAA Transactions.
• Prepared and Created Test Cases /Test Data according to Business requirements.
• Created Statement of Work (SOW) document for various capabilities in the initial requirements gathering phase.
• Strong Documentation experience which required converting business needs to technical documents.
• Documented and reviewed high level and detailed requirements in Business Requirement document (BRD).
• Created Use Cases and Use case Description/narratives based on the requirements list and the BRD.
• Experience in using Microsoft SharePoint to centrally store, manage and access business artifacts across all platforms.
• Created Activity and Sequence Diagrams in UML using Rational Rose and also involved in creating the Business Process Models.
• Coordinated activities involved in QA and User Acceptance Testing.
• Highly contributed to the enterprise metadata efforts by completing the data mapping repository (DMR) information.
• Actively involved in reporting project updates, managing project resources, conflict resolution and maintaining project deadline
• Communicated with business/technology leadership for overall project/program office milestones.
• Monitor the production environment and proactively prioritize, communicate, and resolve any EDI process or system issues.

Environment: Rational / Tele Logic Doors, RUP, HL7 interface, Test Foundation Server, UML, Rational Rose, MS Office, Microsoft SharePoint

Confidential, Parsippany, NJ

Business Analyst

Responsibilities:

• Facilitated (JAD) Joint Application Development sessions to identify business rules and requirements and then documented them in a format that can be reviewed and understood by both business people and technical people.
• Created targeted Questionnaires for SMEs to gather requirements.
• Followed Rational Unified Process (RUP) methodology for creating artifacts.
• Worked with business and technical to develop business requirements for implementation
• Provided primary liaison between business/operations/vendors and development
• Studied and analyzed competitor’s applications and brainstormed to gather effective requirements for a quality product.
• Participated in Design walk-through with SMEs to baseline the business architecture.
• Used Visio to carry out the business modeling and object modeling effort to develop the business architecture for the application for rapid and controlled Application development.
• Created Business Requirements and converted them into System Requirement Specifications.
• Developed and executed test scripts, test cases, data sets and user procedures
• Involved in Requirement Scoping and analyzing high priority requirement for implementation
• Analyzed Requirements and created UML diagrams of Use Cases, Use Case Diagrams, Activity Diagrams using Rational rose and Microsoft Visio.
• Created and maintained Data Dictionary and pursued to reach consensus.
• Used Rational RequisitePro for Managing and Configuring the Requirement Analysis effort.
• Have Good understanding of the compliance rules of FDA Guidelines and CFR.
• Utilized Microsoft Word, Excel, Microsoft Outlook, Microsoft Visio, Microsoft Access, Lotus Notes, Clarity

Environment: Windows NT, JAVA Front end, Oracle Database, MS Office, MS Visio, Rational Rose, WinRunner, LoadRunner, TestDirector, Lotus Notes, Clarity

Confidential, Draper, UT

Business Analyst

Responsibilities:

• Gathered requirements and prepared business requirement documents (BRD).
• Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Involved in business and technical to develop business requirements for implementation
• Developed and maintained all operational and technical flows using Visio and Power point
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models
• Defined Use cases from requirements and helped convert them into software specifications
• Involved in developing and executing test scripts, test cases, data sets and user procedures
• Aided in workflow analysis and process design
• Analyze business requirements from Black Box Testing perspective, business process and system architecture/design
• Maintained Requirement Traceability Matrix (RTM).
• Performed Regression Testing and created test scenarios for User Acceptance Testing (UAT)
• Used MS Office Tools (Word, Excel, Outlook), MS Visio, MS Access, Lotus Notes and Clarity
• Maintained documents for change request and implemented procedures for testing changes.

Environment: Rational Rose, MS Office Suite, Windows NT/XP, Rational Requisite Pro, Web Services, JAVA, Tag Libraries, UML