SUMMARY

• 6+years of experience as a Business Data Analyst in Healthcare & Insurance industry.
• Health Insurance Background - Specifically related to collecting requirements, documenting and representing the business, Use Cases, Business process improvements, etc.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• 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)
• Experienced in data analysis with solid understanding of Business Requirements Gathering, Data warehousing, Business Intelligence, Data Mapping and Data Modeling.
• Experienced in data analysis, data modeling, Conceptual logical modeling and physical database design for Online Transactional processing (OLTP) and Online Analytical Processing (OLAP) systems.
• Responsibilities include gathering business requirements, developing strategy for data cleansing and data migration, writing functional and technical specifications, creating source to target mapping, designing data profiling and data validation jobs in DataStage, and creating ETL jobs in DataStage.
• Have considerable expertise in Metadata Management, Data Analysis, Data Profiling & Quality, Data Governance and Master Data management (MDM).
• Hands on experience in creating Configuration files and deploying into file system and SQL Server database.
• Sound understanding of Object Oriented Analysis and Design OOAD and proficient in documentation of As-is and To-be business processes.
• Succeeded in implementing a Pharmacy Benefits management (PBM) program using encrypted FTP data feeds.
• Documented Data Mappings/Transformations, and Informatica sessions as per the business requirement.
• Deep understanding of HEDIS Reporting, Medical Record Abstraction, Quality Improvement, and Data Analysis.
• Proficient in MS Office Excel (pivot tables, vlookups, hlookups, macro), Access, PowerPoint, Visio.
• Experienced with Medicare and Healthcare Insurance; as well as Medical Standards (HIPAA and HL7)
• Experienced in conducting GAP analysis, User Acceptance Testing (UAT). SWOT analysis, Cost benefit analysis and ROI analysis.
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Knowledge of 837, 835, 834, 277, 270, 271, NCPDP, 4010, 5010 and ICD-9/ICD-10.
• Involved in Design mappings, created data flow diagrams and documented the ETL high level and low level design approach.
• Highly skilled in documenting business and technical requirements along with UI wireframes.
• Knowledge of electronic (HIPAA X12 standards-270, 271, 275, 276, 277, 278,834, 835, 837, and 997) and paper claim forms such as UB04, HCFA-1500, CMS1500, etc.
• Extensive experience in AMISYS, FACETS, SQL, EDIFACTS, XML, RUP and SDLC.
• Proven expertise in creating test plans, UML diagrams, flowcharts, screen mockups and systems requirements specifications.
• Experienced in manual and automated testing for both front-end and backend. Extensively used automated test tools of Mercury like Quality Center, Quick Test Pro, Win Runner, Test Director, Performance and Load Runner Testing.
• Have gained understanding and experience on data acquisition, data integration and data aggregation including experience working with data-feeds which included market data and internal feeds.
• Extensive Knowledge about all the phases of Business Analysis Life cycle like Requirements Elicitation, Requirements Analysis, Requirements Documentation and Requirements Management.
• Extensive experience in writing Use Cases and UML diagrams.

TECHNICAL SKILLS

Business Tools: Rational Suite (Requisite Pro, Rose, Clear Quest, Clear Case), MS Visio, MS Project, MS Access, MS Office Suite, PowerPoint, Outlook, Visual Paradigm, Doors, Erwin, Data Modeler 4x, Business Object (Crystal Reports)

Business Skills: Business Definition Requirements, Business Process Analysis, Gap Analysis, Use Case Modelling & Analysis, Business Environment

Methodologies: RUP, OOAD, AGILE, Scrum, Waterfall, UML & Business/Data Modelling

Testing Tools: Win Runner, Load Runner, Test Director, Quick Test Pro, PR Tracker

Operating Systems: Windows XP/95/98/NT/2000, Mac OS X, DOS, UNIX, Linux

Databases: Oracle 8i/9i; SQL Server 7.0 & 2000; Access 2000, MS SQL Server, MySQL, DB2

Content Management Tools: Documentum, Sharepoint, Filenet

Languages: UML (Use case, activity diagram, sequence diagram, data flow diagram, component diagram), C, C++, HTML, Java, SQL, PL/SQL, ASP.NET, XML

PROFESSIONAL EXPERIENCE

Confidential -Atlanta, GA

Business Data Analyst

Responsibilities:

• Involved in all phases of software development life cycle (SDLC) in RUP framework. .
• Utilized the Legacy System Migration Workbench (LSMW) tool to load data into various the SAP Systems (Development, Acceptance, Quality and Production).
• Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirements and hands on experience in Supply Chain Management (SCM).
• Involved in Six Sigma process analysis and lean methodology.
• Prepared an ROI analysis report after evaluating the COTS product of the multiple business lines
• Used Six Sigma Methodologies in solving the errors and issues while the development of the project.
• Research innovative solutions and propose user stories to support ongoing enhancements of Business Units/systems (Claims,Actuarialand Predictive Analytics) to meet organizational objectives during implementation of the new Claims Data Mart and Front End Data Intake system.
• Excellent knowledge of industry standard methodologies like Software Development Life Cycle (SDLC), Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP), Agile, Scrum, Kanban/Lean, CMM (Capability Maturity Models).
• CARE Management; developed Operational Support Services, Service Level Agreements, improved customer relations scores with Public Safety clients - set up and managed periodic CARE Management reviews with customers.
• Performed HIPAA Analysis and Testing on4010/5010, including Claims handling, with Payer and Provider experience and EDI file generation and testing.
• Knowledge of EMR/EHR, Patient Protection and Affordable Care Act (PPACA).
• There are no co-pays for members as the company is a Managed Medicaid and Medicare Advantage Company With the implementation of the Affordable Care Act, CareSource entered the health insurance marketplace.
• Experience with TriZetto Facets 4.21/4.31 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Documented requirements and workflows for AMISYS Advance modules/subsets including Provider, Member, Claims and Benefits.
• Prepared Test data for AMISYS files to enable the software to be quality checked.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Performed in depth data analysis identifying data issues in legacy system and worked with business to develop resolutions to those issues.
• Implemented Master Data Management (MDM) for all the high level entities in the project by maintaining a master hub for improving the data quality by following various data governance techniques and data dictionary standards.
• Researched data issues and identify the root cause in source systems, data warehouse and data marts using various data analysis techniques, data profiling and data mining activities.
• Informatica Data Quality (IDQ) used for data quality measurement.
• Established Data Management Office and Chair Data Governance and Business Intelligence councils, implemented global Data Governance, Data Stewardship and Data Quality monitoring processes, standards, policies and executive reporting dashboards.
• Performed data analysis and data profiling using complex SQL on various sources systems including Oracle and SQL Server.
• Advanced ad-hoc and standard report development, including data analysis through the use of Oracle Discover, Business Objects, TOAD, Erwin, Excel, Access, SAS, SQL, and Oracle Reports.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Analyzed the current billing and claims data provided from existing BRD’s (Business Requirement Document).
• Create and maintain data model/architecture standards, including master data management (MDM).
• Provided input to the HEDIS system that used Quality Compass to provide a selection base for various healthcare plans.
• Daily validation of batch files for Enrollment and Billing and discussing error with internal and external parties.
• Working within a growing knowledge of X12 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid
• Conducted ICD-9/ICD 10 conversion analysis through ICD 9 and ICD 10 proposed mapping documents and HIPAA 5010 system capabilities of EDIFECS tools. Update mapping documents as required for version upgrade and change requests.
• Analysis and Design of Migration Procedures for the DB Migration between Relational and Extended ERP Data Sources. Performed Database Migration from sources to the Data Warehousing database. Worked closely with Oracle DBA for migration support.
• Recommend tactic to implement HIPAA 4010 ( EDI X12 837,834,278,270) in the new System
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Developed straightforward DBMS queries, knowledge of HL7 and XML interface messaging.
• Migrated Data from MS Excel to SQL Server Reporting Service Using DTS and SQL loader utilities.
• Design, development, implementation and roll-out of Microstrategy Business Intelligence applications
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, Primavera, Promodel, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams.
• Use of data transformation tools such as DTS, SSIS, Informatica or DataStage
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.

Environment: Windows /XP, Microsoft Office SharePoint 2007, Rational Requisite Pro, MS Office, XML, SOA, SQL Server, Agile, MS Project, MS FrontPage, MS Access, MS Visio, MS Excel, MS word, EDI, Facets, Kanban, Documentum.

Confidential -Cleveland, OH

Business Analyst/Data Analyst

Responsibilities:

• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Complete understanding and hands on experience of Pharmacy Benefit Management System and Health Insurance in the United States, in depth knowledge of Health Care Laws and ICD Standards.
• Executed all aspects related to employee health insurance, worker's compensation, life insurance, long/short term disability, employee discount/store benefits including company events coordination.
• Writing functional and technical specifications, creating source to target mapping, designing data profiling and data validation jobs in DataStage, and creating ETL jobs in DataStage.
• Strong experience in the Data Analysis, Data Profile, Data Quality, Design, Development, Implementation and Testing of Business Intelligence applications using ETL and ELT methodology.
• Maintained and enhanced the existingActuarialapplication for data mining and predictive modeling.
• Master Data Management (MDM): Initiated a cross-functional project to identify what master data to manage and defined a process to collect, aggregate, match, and consolidate, quality-assure, maintain and distribute such data throughout the company.
• Responsible for implementing supply chain and operations solutions in the exploration & production lines.
• Performed Gap analysis for the modules in production, conducted feasibility study and performed impact analysis for enhancements, Cost benefit analysis and ROI analysis.
• Performed data analysis and data profiling using complex SQL on various sources systems including Oracle and SQL Server.
• Performed data analysis, data reconciliation and data retrieval from various systems along with identification of data gaps and data quality.
• Worked on Data Mart responsible for gathering requirements, preparing functional specifications and BI Business/Data Analysis / Modeling and UAT.
• 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.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Knowledge of 837, 835, 277, 270, 271, NCPDP, 4010, 5010 and ICD-9/ICD-10.
• Experienced with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Provided input to the HEDIS system that used Quality Compass to provide a selection base for various healthcare plans.
• Developed BRDs, FRDs and FSDs using corporate templates; developed Use Case Diagrams, Activity Diagrams and Sequence Diagrams using UML.
• Worked on Documentum for Version Controlling, to maintain up to date changes in the Documents.
• Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
• Analyze and prepare specifications for the improved functionality of the Nasco.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Tested the ETL Informatica mappings and other ETL Processes (Data Warehouse Testing).
• Conduct Business Rule Definition JAD session and Requirements Gathering JAD sessions
• Define and document client requirements for installations and manage requirements with changes
• Seek flexible, globally applicable system solutions to client requirements (HIPAA compliancy)
• Completed the documentation of Claims Scenario’s for the source system.
• Presented detail walk through of Functional Specifications, Detail Design and VISIO work flow process diagrams to Business, EDI, MQSI, HIPAA project managers and HIPAA project regulators.
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Involved in project management using MS Project
• Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, DataStage, Data Warehousing, Websphere and Cognos.
• Generated daily, weekly, and monthly reports using MS OFFICE Tools and submitted to the Team Leads and Manager for reporting, status reporting and analyzing purpose.
• Developed UML Use Cases for the application and prepared the detailed Work flow diagram based on the proposed enhancement for the system.
• Collaborated with External Auditors and documented SOX compliance requirements
• Lead internal design meetings, create mapping and design documents (834s, 835s and 501s)
• Wrote test cases and test scripts for the User Acceptance Testing (UAT).
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Created DTS and SSIS Packages to vendors in which records were loaded Daily, also to other data resources such as Excel, Access, flat file, and XML in order to Create and maintain a centralized data warehouse.
• Was also involved in developing UNIX shell scripts to emulate mainframe JCL.
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.

Environment: Facets, Windows XP Professional, Oracle, XML, SOA, MS Access, MS Excel, MS Visio, MS project, RUP, Oracle, UML, SQL, Rational Rose, Requisite Pro, Clear Case, Rational Clear Quest, MS Office suite, MS Visio.

Confidential, Chicago, IL

Business System Analyst

Responsibilities:

• Worked according to the activities/roles laid down in each phase of software development life cycle created using Rational Unified Process.
• Assisted technical teams in creating ER Diagrams; wrote complex SQL Queries for Data Analysis; well versed with Data Modeling, Data Flow diagrams, System Architecture, User-Interface design, Data Warehouse, RDBMS.
• Gathered data from the legacy system (db2) to the present updated system using data warehouse tools such as Informatica
• XML order header and order detail data transfer; inventory/supply chain management modules.
• Expertise in B2B standards, Implementation of Integrated EDI and XML applications and Enterprise Application Integration (EAI) for business processes across applications.
• Working within a growing knowledge of X10 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Worked with Data Warehouse in the development and execution of data conversion, data cleaning and standardization strategies and plans as several small tables are combined into one single data repository system MDM (Master Data Management)
• Designed the Data Warehousing ETL procedures for extracting the data from all source systems to the target system.
• Responsible for developing Front end edits for claimsadjudication
• Develop MITA Maturity Model (MMM) & Business Capability Matrix (BCM) to identify the maturity level of SD Medicaid Enterprise.
• Involved in performance testing of Medicaid client server claims processing system, Medicaid MCC / MCO and Medicaid Management Information System (MMIS)
• Participated in UAT and worked with Mercury Quality Center for bug and defect tracking.
• Worked on EDI transaction 835 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Worked closely with data warehousing team for the data integration on the Hansel and Pie systems.
• Authored test plans, test cases for various test scenarios and helped testing team to better understand the test scripts.
• Applied RUP methodology with its various workflows, artifacts and activities to manage life cycle from Inception to Transition phase.
• Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared Business Requirement Documents (BRD) using Rational RequisitePro.
• Prepared a Project Charter and a detailed Business Requirements Documents (BRD).
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access. Produce performance reports and implement changes for improved reporting.
• Developed Use Cases in Microsoft Visio along with Activity Diagram to present the workflow in a visual form.
• Performed task decomposition, delegated tasks and monitored project milestones using MS Project.
• Developed test cases and scripts based on business requirements for the functional, User Acceptance, Performance, Integration testing, System Back-end Testing and End-To-End testing.
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team

Environment: RUP, UML, Word, Excel, PowerPoint, SQL, Project, Visio, SharePoint, ADR, IBM Web sphere, J2EE, Mercury Test Director, Lotus Notes, Facets, Rally.

Confidential, Trumbull, CT

Data Analyst

Responsibilities:

• Used Agile Scrum for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Worked with end users for BI data analysis and data validation.
• Performed data analysis and data profiling using complex SQL on various sources systems including Oracle and SQL Server.
• Meticulously assessed data from various sources and generated conceptual and logical database designs using Erwin data modeling tool.
• Created and maintained data model/architecture standards, including master data management (MDM).
• Data profiling, validating, monitoring and cleansing across the enterprise through Informatica Data Quality (IDQ).
• Strong experience in the Data Analysis, Data Profile, Data Quality, Design, Development, Implementation and Testing of Business Intelligence applications using ETL and ELT methodology.
• Assisted other project teams with data analysis, data mining and data profiling as needed.
• Elicited, documented, modelled, validated and prioritized functional and non-functional requirements using interviews, data analysis, and different modelling tools.
• Worked on eligibility files with the Claims dept. ensuring all the data and enrollments were correct and updated in AMISYS Advance.
• Facilitated, documented and oversaw the provider set-up and contract configuration in AMISYS Advance.
• Experienced in large enterprise projects, leadership experience, requirements interviewing, meeting facilitation, project management, state health/public health, HEDIS, SOA.
• Worked on requirements and completely developed the new process for HEDIS data processing.
• Strong knowledge of managed care payer requirements and procedures.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Experienced with Medicare and Medicaid: Claims processing, Membership, and Eligibility Verification and care management.
• Provided test data to all the testers including UAT Business Edge team and UI testing team.
• Involved in Utilization management, Claims adjudication, grievance and appeals, 820, 834, 837/278 EDI transactions to update claims and Prior Approval (Pre authorization) process for professional and Facility claims.
• Involved in preparing Test Data based on the functionality of all the HIPAA Related Transactions (837/835, 270/271, 276/277) and AMISYS transactions.
• Used Guidelines and artifacts of Agile (Kanban) SDLC.
• Used MS Visio to create business process flowcharts and workflow diagrams, Involved in detailing project mission, Data Process Flow Diagrams and timelines, prepared data interfaces using XML and JSON data formats.
• Very good understanding of Business Intelligence and Data Warehousing concepts with emphasis on ETL and Life Cycle Development including requirements analysis, design, development, testing and implementation.
• Proficient in RDBMS concepts and also in database testing using PL/SQL tools such as TOAD.
• Uploaded the technical specification documents to Planview SharePoint portal.
• Maintaining SQL Script for creation of Database Objects using VSS (Visual Source Safe).
• Created .NET Reports which are used to present the data in different views and are effectively consumed using Crystal Reports.
• Succeeded in implementing a Pharmacy Benefits management (PBM) program using encrypted FTP data feeds.
• 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.
• Knowledge in the ETL (Extract, Transform and Load) of data into a data warehouse/date mart and Business Intelligence (BI) tools like Business Objects Modules (Reporter, Supervisor, Designer, and Web Intelligence).
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Involved in testing the conversion of the application into web application using XML web services.
• In an agile environment created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams, and Collaboration Diagrams thus defining the Data Process Model and Business Process Model.
• Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
• Wrote Test Cases in Mercury Quality center that would test various Test scenarios.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Facilitated JAD sessions for Requirement Validation with HPA to gather requirements for the new MMIS.
• Created Data Flow Diagrams (DFDs), ER diagrams for database modeling and Web-page mock-ups using MS Visio for acceptance from analysts, surveyors and customers.
• Planned and documented procedures for data processing and prepared data flow diagrams for the application in iSeries RPG environments
• Involved in generation and execution of SQL queries.

Environment: Medicare, Oracle, FACETS, Agile, Medicaid, HIPAA-compliant patient information management and billing system and Microsoft Office package, Metadata, Data Warehouse, SQL, RDBMS, Erwin, Oracle, Rally, Rose, MS Word, MS PowerPoint, MS Excel, MS Visio,