PROFESSIONAL SUMMARY

• 7+ years of extensive experience as a Business Analyst/ Business System Analyst in Health Care Insurance, and Claims Processing with solid understanding of Business Requirement Gathering, Data analysis, Data Mapping, Data Modeling and Business Process Modeling.
• Proficient in different software/system development life cycles (SDLC) methodologies such as RUP, Agile - Scrum models and Waterfall.
• Worked on reporting and estimates on Guidewire ClaimCenter implementation and worked with the stakeholders to gather requirements for ClaimCenter implementation.
• Experience in conducting GAP analysis, User Acceptance Testing (UAT), SWOT analysis, Risk Analysis, Feasibility Analysis and mitigation plan, Cost benefit analysis, and ROI analysis.
• Excellent knowledge in MS Excel-Pivot tables, graphs and MS PowerPoint
• Worked on MS project, Resource plans, MS Excel Macros.
• Participated in managing and maintaining the claims processes using ClaimCenter.
• Experience in implementing HIPAA Gateway EDI X12 Transactions. Experienced in HIPAA transactions EDI 837 (Health Care Claims), 835(Payment/Remittance Advice/Explanation of Benefits), 270 (Eligibility Request) / 271 (Eligibility Response), 276 (Claims Status Inquiry Request) / 277 (Claims), Status Inquiry Response), 834(Benefit Enrollment and Maintenance Transaction), 997/999 (Transaction Acknowledgement). Presented several documents and Use Cases for these transactions.
• Dynamic experience in Health Administration Claims processing (Auto adjudication), COB/EOB, Claims pricing and testing, HIPAA, PPACA enrollment, EDI, Medicare, Medicaid, CDHP.
• Identified, coordinated and scheduled System critical tasks. Performed software and technical assessments in concert with business representatives and other members of the staff. Involved data flow model and work flow analysis
• Utilized experience withAGILEsoftware development paradigms to help drive projects and manage / coordinate multiple initiatives and development teams (including offshore/remote teams).
• Experience in preparing various documentations like Business Requirement Document (BRD), Functional Requirement Document (FRD), Functional Specification Document (FSD), Data Mapping Document (DMD), Report Specification Document (RSD), Requirement Traceability Matrix (RTM) and other client specific documents.
• In depth knowledge of MMIS, HIPAA, CFS, ACA standards, ICD codes, HIX and HL7.
• Experience with implementation of Health Insurance Exchange (HIX) and member enrollment.
• Excellent experience in developing and executing Test Procedures, Test Cases, Test Scripts, Test Plans, performing Functional Testing, Compatibility Testing, Usability Testing, Stress Testing,UAT.
• In depth knowledge of Medicare Part A, B, C and D / Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors.
• Excellent interpersonal communication skills, analytical thinker and a quick problem-solver.
• Understanding of insurance policies like HMO and PPO and proven experience with implementing HIPAA Gateway EDI X12 Transactions.
• Experience in conducting JAD sessions / Facilitated sessions for project definition involving analyzing requirements, creating prototypes, and user interface documents.
• Proficient in Developing and executing Test Plans, performing functional, usability testing and ensuring that the software meets the system Requirement.
• Strong analytical skills with detail follow-through and skills in business process mapping and analysis.
• Excellent communication and presentation skills with experience in the development, implementation and integration strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills.
• Excellent technical abilities and skills developed by a strong work ethic and self-learning.

TECHNICAL SKILLS

Requirement Management: JIRA and Microsoft Office Suite, Rational Rose Suite, BluePrints

Quality Testing Applications: HP Quality Center / ALM and BugZilla, JIRA, ClearQuest, ERWIN

Project Management: MS Project (Server), JIRA, XML, BI

Databases: SAS, SQL Server, Oracle, My SQL, IBM, SSIS, and MS Access, Teradata

Applications: MS SharePoint, Office 365, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Rational Suite, MS Visio, GuideWire ClaimsCenter, FACETS

Methodologies: Agile-Scrum, RUP, Waterfall

Data Warehouse Tools: IBM-Cognos Data Manager, Informatica-Power Center, MS SQL Server Integration Services, Oracle-Data Integrator/ Warehouse Builder, SAS- Data Integration Studio, SAP- Business Objects Data Integrator, and Tableau

Other Tools: Toad, SQL Management Studio, QTP, Business Objects and SQL Developer, HP Extreme

PROFESSIONAL EXPERIENCE

Confidential, Long Beach, California

Senior Business Analyst

Responsibilities:.

• Worked with Leadership hierarchy for discussing high-level project reports and reporting project status.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Facilitated JAD sessions to collect requirements from system users and prepared Business Requirement Document (BRD) that provided an appropriate scope of work for the technical team to develop prototype and overall system.
• Created Test plans and Test cases based on the business requirements.
• Extensively involved in planning efforts for the Health Insurance Exchange (HIX).
• Experience with claims, enrollment, and eligibility verification for members and providers, benefits setup, and backend payment cycle.
• Developed the ETL Informatica Mappings for importing data from ODS into subsequent data marts.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 EDI (834- Benefit Enrollment and Maintenance, 837- Health Care Claim) standards.
• Created and maintained the Requirements Traceability Matrix (RTM).
• Worked with the Project Manager (PM) on various Project Management activities like keeping track of project status, deadlines, environment request, and compliance issues.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid claims.
• Worked with Providers & Medicaid entities to validate EDI transaction sets.
• Worked closely with project manager and other users, producing work flow diagrams using MS Visio/UML.
• Ensured Use Cases were consistent and covered all aspects of the Requirements and Specifications document.
• Was responsible for tracking issues that are detected and updating the status of existing issues based on the daily Scrum meetings with the project team. Performed Root Cause Analysis and Risk Analysis to track these issues.
• Gathered user and business requirements through open-ended discussions, brainstorming sessions and role-playing.
• Identified and analyzed the data requirements for the various teams and made sure that the required data is available in the testing environment.
• Worked directly with development team to ensure clear communications on requirements and Defect Status Reports.
• Was involved in Functional System Testing, Integration Testing, Regression Testing, and User Acceptance Testing using the test cases and test plans before releasing the application.
• Involved in project status meetings, QA review meeting, and System Test meetings.
• Created test cases and test plans for the User Acceptance testing (UAT).
• Led JAD sessions with management, development team, users and other stakeholders to refine functional requirements and to identify the business flows.
• Prepared Logical Data Models using ERWIN that contains sets of diagrams and supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the data elements to analyze the document data requirements.
• Assisted Risk Management Group in Financial analysis and Risk analysis on calculation of PV, FV, standard deviation and variance, and other key trade metrics (e.g. Breakeven Rate) to test new Risk Analytic Tool.
• Assisted clients in resolving billing issues for Medicare,Medicaid, and private insurance.

Environment: Facets, HP ALM Quality Center, SAP, ERWIN, Informatica, IBM, BizTalk, UML, MS Visio, SQL Server, MS Office, Agile, Claims Data Validator, MS project, SharePoint, HP Extreme

Confidential, Bismarck, ND

Business Analyst

Responsibilities

• Evaluated business process requirements to ensure proper system configuration (i.e. identifying key decisions, process changes, pain points, interface issues, training considerations, etc.)
• 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.
• Understood the healthcare plans offered, including Medicaid Managed Plans such as Children and Adolescent Care, Women’s Preventive Care, Maternal Care, Asthma Care, Diabetes Care, Cardiovascular Care, and Mental Health.
• Gathered AS-IS and TO-BE information for work processes and information flows (Claims Process, Membership, Enrollment), and conceptualized using activity diagrams.
• Created and reviewed User Requirements Document, Use Cases, and Functional Requirements Document.
• Used the Agile methodology to build the different phases of Software development life cycle (SDLC).
• Helped drive projects and manage / coordinate multiple initiatives and development teams (including offshore/remote teams).
• Gathered and prioritized requirements, developed business scenarios to check how the system would work with the roles and processes of the departments, and developed acceptance criteria.
• Facilitated review of Enrollment, Claims, Commissions, and membership portlets’ designs with architects and developers to ensure that the goals of the portal requirements were satisfied.
• Conducted GAP analysis in theAGILEprocesses.
• Produced UML Activity diagrams using MS Visio as part of claims process analysis.
• Brought valuable knowledge and solutions to business groups to enhance competitive edge with Facets Extended Enterprise(TM) administrative system implementation.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and AGILE.
• Contributed in the build and design of an automated documentation system that met business process needs by providing comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management
• Facilitated testing for HIPAA Gateway Application Interface, for all inbound and outbound messages (270/ 271,276/277, 837, 835, 834).
• Requirements Elicitation - researching, interviewing, gather business requirements by conducting detailed interviews with business users, stakeholders, and Subject Matter Experts (SMEs).
• Used the Data Stage Designer to develop processes for extracting, cleansing, transforms, integrating and loading data into data warehouse database.
• Involved with various aspects of the project’s needs such as the logging, tracking, and resolution of issues, current state workflow assessments and assisting with integration testing.
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.

Environment: SQL Server, MS Visio, Lucid chart, XML, HP Quality Center, Oracle, MySQL, MS Access, SharePoint, Microsoft Word, Microsoft Excel, DataStage

Confidential, Charlotte, NC

Business Systems Analyst

Responsibilities:

• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD. Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Worked with scrum master to break the requirements into user’s stories and sprints.
• Closely worked with data analyst team in defining sources and content for the data ware house component. Work on the integration of data from various sources, created comprehensive data mapping and dataflow diagrams.
• Actively participated in weekly meetings and ad hocks meetings with PM, stakeholders and delivery mangers throughout the life cycle to identify and track project issues and risks.
• Strong understanding of Medicaid Management Information System (MMIS), Patient Protection and Affordable Care Act (PPACA), Health Level Seven International standards (HL7), Health Care Reform, and Claims EDI
• Organized meetings and led JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met.
• Review HL7 requirements for interfaces with various third-party software applications.
• Read and analyzed the federal legislation to update the products as per the mandated provisions of HCR (Health Care Reform).
• Created and maintained Service Level Agreements (SLA’s) and wrote business rules pertaining to the HIX project.
• Created use cases diagrams and business process workflows using Visio
• Implemented various EDI transactions like enrollment (834) and premium payment (820) to support HIPAA transaction set.
• Got a great exposure to Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems.
• Worked with the UAT and QA teams to conduct an assessment and determine how effective UAT and QA guidelines can help the company achieve timely completion of projects.
• Effectively elaborated the Current process and gave a clear picture of the proposed process for the projects in the organization. Worked aggressively towards timely completion of High Priority Tasks.
• Participation in a HP Quality Center for System Integration Testing support and help finalizing defects.
• Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Worked with IT to resolve issues and clarify Business Requirements from the Business Owners.
• Wrote test cases, test script and test plan for testing.
• Documented the UAT Test Plan for the project and worked with the UAT team to ensure every acceptance criteria for the requirements that has been included in the UAT task plan.
• Maintained the Traceability Matrix table to uniquely trace the identified business requirements from general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked.

Environment:UML, Windows, SQL, Microsoft Office, HP/Quality Center, Agile, MS Access, MS SharePoint, HTML, XML, Java, DB2.

Confidential, NY

Business Analyst

Responsibilities:

• Conducted JAD sessions, one to one and group interviews with SMEs, stakeholders and senior management for gathering requirements.
• Exposure to HIPAA compliance requirements as well as 835 and 837 transactions sets; documented and managed business and functional requirements for HIPAA 5010 version
• Performed GAP analysis between HIPAA 4010 and 5010 and involved in evaluating benefits of new system with the management team to strategize solutions to the process of HIPAA compliance
• Implemented Agile methodology through scrums, sprint planning and review meetings to generate Business Requirement Document (BRD) and Functional requirement document (FRD), Use cases and work flow diagrams
• Designed a claim processing system for the healthcare management client system.
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Business Process Management (BPM) tool.
• 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.
• 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.
• Developed plan for data feeds and data mappings for integration between various systems, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Conducted Gap Analysis, and Gathered User Requirements by Interviews, user meeting, JAD session, and Requirement Elicitation Sessions.
• Utilized corporation developed Agile SDLC methodology. Used Scrum Work Pro and Microsoft Office software to perform required job functions.
• Assisted to develop the Test Plan, Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge.
• Conducted User Acceptance Testing (UAT) and developed SQL queries in MS Access and Oracle for data manipulations.

Environment: HIPAA, Agile Methodology, UML, MMIS, MS Office Suite, Windows, SharePoint, RUP, Oracle SQL