SUMMARY

• Solid understanding of Business Requirement gathering, Business Process flow, Business Process Modeling and Analysis, Technical design documentation, Project management.
• Experienced in all phases of the Software Development Life Cycle (SDLC), Rational unified process (RUP), agile methodology.
• Experienced in conducting Joint Application Development JAD sessions, workshops etc.
• 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.
• Experienced in performing Business Process Reengineering/Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Managed complex business initiatives to balance requirements for functionality, efficiency and quality.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Extensive experience in claims processing and billing, Medicare/Medicaid billing and claims management.
• Proficient in ICD - 9-CM and ICD -10-CM coding and claims processing
• EDI healthcare experience working with implementation guides, TR3s.
• Strong knowledge of HL7, HIX (Health Insurance Exchange), EMR/EHR, Health Care Reform and Patient Protection and Affordable Care Act (PPACA) and Facets.
• Extensive knowledge of Healthcare Insurance including Medicaid. Medicaid Information Technology (MITA), Medicare (Part A, B, C, D), Procedural and Diagnostic codes, Claims Process and Medicaid Management Information Systems (MMIS)
• Have experience with Healthcare Interchange which included Consumer Portal, Care Coordination Portal and Healthcare Partner Portal.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules such as EDI 837,270,271,276,277,834,835.
• Experienced with Rational tools like ReqPro, Clearquest, ClearCase, Rational soda, Rational Rose.
• Experienced working in Medicare and Medicaid projects.
• Expertise with ISO, Six Sigma, CMM standards.
• Expertise in handling issues and getting it solved in a quick and efficient manner.
• Proficient in developing UAT plans, UAT cases, UAT scripts and executing UAT.
• Proficient in writing queries/ SQL/ MS Access to assist in UAT, data validations and data analysis.
• Experience in Rational Unified Process (RUP), Rational Requisite Pro, Rational ClearQuest, and Microsoft Project.
• Experience using Rational Rose, and MS Visio for business process modeling and designing data flow diagrams (DFD).
• Exceptional Documentation Skills for writing Use Cases and Functional Requirement Documents.
• Expertise in creating Use Case diagrams, Activity diagrams, Data Flow Diagrams (DFD), Sequence diagrams, State diagrams based on UML Methodology and business process flow diagrams using MS Visio/Enterprise Architect/Rational Rose.
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Good Knowledge of Test Plan, Test Scripts and Test Cases for Functional, System, Integration, UAT, and Regression Testing based on the Design Document and User Requirement Document for the Functional, Security, and Performance Testing.
• Excellent written and verbal communication.
• Extensive expertise in databases like Oracle, SQL.
• Strengths include quick learner, problem-solving capability, and ability to work as team player and lead the teams.
• Consistently demonstrated ability to achieve tight deadlines.

TECHNICAL SKILLS

Operating Systems: Win 98/XP/Vista/Windows 7, UNIX, LINUX, Mac.

Languages: C, C++, Java, SQL, HTML, XML, C#, VB, ASP, .Net

Databases: Oracle, MS SQL server, MS Access, IBM DB2

Tools: MS Office: Word, Excel, Access, Power point, Project, Visio, Front Office, Rational Rose, Soda, Software Modeler, Team Test, Doors, PROLOG, Clearcase, Clearquest, QTP, LoadRunner, WebSphere, Business Modeler, HP Quality Center, Ultra Edit, TOAD and Test Director, TFS

Industry Standards: HIPAA, SOX, ISO, Six Sigma, CMM.

PROFESSIONAL EXPERIENCE

Confidential - Houston, TX

Business Analyst

Responsibilities:

• Analyzed discrepancies in enrollment transactions for health care exchanges.
• Worked on updates needed in enrollment transactions for federally facilitated exchanges and state partnership exchanges.
• Conducted meetings/JAD sessions to understand the requirements from client.
• Worked directly with client to document the business rules and develop business requirement documents.
• Analyzed enrollment transactions based on business rules provided by client.
• Prepared meeting minutes after meetings to keep track all the requirements/rules.
• Served as a mentor for team members to provide training and guidance in working cases and case management.
• Performed data mining for the cases to retrieve enrollment information.
• Worked on EDI 834 AND 820 for testing enrollment transactions.
• Reviewed documents provided by CMS for enrollment reconciliation.

Environment: MS Office, SharePoint, Multidimensional Insurance Data Analytics System (MIDAS)

Confidential - St. Louis, MO

Business Analyst/Project Manager

Responsibilities:

• Created mapping documents for the files generated using SSIS packages.
• Conducted meetings/JAD sessions to understand the requirements from client.
• Developed technical design documents from the functional requirements and JAD sessions.
• Developed several unit test plans for testing of all the files generated.
• Developed and maintained change control forms for the migration of interfaces to other environments like STAGE/PROD.
• Worked interactively with developers to explain the requirements and data extract criteria for the generation of files.
• All these files have information from claims application like payer, provider and member.
• These files included information for generating EDI 276/277 (claim status), 835 (payment), Medicare/Medicaid plans member enrollment status of a member, HCFA/UB claims information, Part C EOB, Sales agents/broker commission based on the enrollments, member/provider address verification etc.
• Acted as project manager/lead for the whole span of the project.
• Created and maintained scheduling document and project plan.
• Coordinated and attended several project manager meetings.
• Prepared meeting minutes after meetings to keep track all the requirements/rules.
• Prepared level of effort and estimation sheets for the project.
• Proactively identified the next steps in the project to meet timelines.
• Have used SQL server extensively in creating queries for testing the files, data extract criteria, to compare back end data with UI.
• Maintained, analyzed and reported issues/bugs in TFS. Conducted extensive testing and took actions to remediate bugs opened while integration testing.

Environment: MS Office, SQL Server, MS Project, IKA systems, TFS, Visual Basic.

Confidential

Business System Analyst

Responsibilities:

• Acted as a liaison between Business area Subject Matter Experts (SMEs) & development team throughout all phases of SDLC; starting from Inception to Transition phase of Rational Unified Process (RUP) methodology
• Participated on meetings related to HIX impact on systems and the subsidies.
• Identified AS-IS process flow of ICD-9-CM and ICD-10-PCS compliance requirements using the gap analysis for the existing United HealthCare community Plan.
• Updated data processes, data reporting, data collection tools and other processes such as problem lists, writing orders, referrals according to ICD-10 code set.
• Ensured that ICD-9-CM procedure codes used for services and CPT codes were not outdated
• Contributed in ICD-10 Awareness Training Management Plan, created evaluation tool, and survey questions
• Reviewed state documents (policies, manuals, business processes, systems documents, banners, bulletins) from various divisions. Analyzed and performed quality assurance to determine areas impacted by ICD-9 related data
• Generated numerous Business Requirement Documents & Functional requirements specification documents, Use cases, system flow and work flow diagrams.
• Worked with the Managed Care Subject Matter Expert (SME) and Users to ensure that all the requirements for system change are covered.
• Worked on various modules of MMIS
• Extracted and refined user requirements by conducting JAD sessions, facilitating meetings & interview with Business Units and Technical Supports & Development team, identifying the business flows and process flows, conducting detailed and comprehensive business, functional & system analysis to determine High Level and Low Level artifacts & deliverables.
• Developed business and detailed functional requirements related to changes to be made to the claim entry screens, including Practitioner, Crossover Practitioner, Dental and Hospital Claim Entry Screens.
• 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.
• Incorporated and updated all MMIS screens for NPI Implementation within the MPS1 subpart used for paying claims
• Created new screen layouts and identified locations for new fields being added and existing fields which are being moved.
• Developed business and functional requirements for the National Provider Identifier (NPI) Crosswalk and Crossover Claims Crosswalk solution.
• Developed Test Plans and Test Execution Procedure Document based on the Business & Functional Requirement Document and numerous Test Cases and Test Scenarios to cover overall aspect of quality assurance.
• Successfully tested all the test conditions, documented the defects and discussed with technical analysts the discrepancies between expected and actual results for the test conditions.
• Conducted knowledge transfer sessions which were used to make the users and other teams aware of all the changes being made in the system as part of various projects.
• Assisted End User in performing User Acceptance testing and performed testing of the end result files created by the development team to verifying whether all the User Requirements were catered to by the development effort.
• Worked with Team Leads, Technical staff and key users to identify track and manage project issues as they arise.
• Developed workflows that demonstrate current and proposed business requirements.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: MS Office, SQL Server, MS Project, MS Visio, Unix, J2ee, Java, XML, Windows XP

Confidential - San Diego, CA

Business Analyst

Responsibilities:

• Gathered Business Requirements. Interacted with the Users, Designers and Developers, Project Manager to get a better understanding of the Business Processes.
• Responsible for the full HIPAA compliance lifecycle from Gap Analysis, mapping, implementation and testing for TennCare processing of Medicaid Claims.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Developed gap analysis document, logical and physical design and remediation plan for State.
• Responsible for mapping documents, creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Worked with business owners, content staff, IT and other stakeholders in creating a content management solution for managing the information in the supplier portal using WebSphere Application Server.
• Built and customized SoDA for Word templates and extract information from information sources such as RequisitePro and Rose, and created a highly automated system for handling approvals, exceptions and priorities.
• Used the Rational Unified Process (RUP) to build the different phases of Software development life cycle
• Created Project management plans for managing on time delivery using MS Project along with writing test cases, unit and systems integration test plans in QualityCenter.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.

Environment: OO Modeling, Web Sphere, Rational RequisitePro, Rational Rose, Rational SoDA, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.