SUMMARY:

• 7 years of experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.,)HL7, Eligibility and Benefit systems, ICD - 10, HCPCS, CPT, Claims Adjudication and expert in Affordable Care Act(ACA), aka Healthcare Reform (HCR).
• Experience planning, developing and implementing EDI Trading Partner Set-up and mapping.
• Having extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, ICD-10, system, Medicare andMedicaid,CMS Compliances/Regulations, Patient Protection and Affordable Care Act (PPACA),
• Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrollment, 835 Claim Payments, 829, 270-278 and many other healthcare maps.
• Knowledge on claims process and adjudication in the Medicare Part A, B, C and D,Medicaid, Managed care, Private and TPA Insurance Sectors.
• Involved in Facet Implementation and conversion in TriZetto Facets and TriZetto HIPAA Gateway.
• Expertise in Membership Enrollment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis.
• SQL application management, (added users, created backup and recovery plans, ran SQL scripts).
• Thorough knowledge of ICD-9, ICD-10 codes and CPT codes for both Mental and Medical Health.
• Experience in Performance Tuning of SQL and Stored Procedures.
• Strong knowledge of EDI Claims, member enrollment, plan/product and billing transactions
• Exceptional knowledge in testing phases with state HIX projects.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Responsible for contacting insurance companies, patients, relatives, and/or patient employers to verify necessary benefits information for proper Medicare claims processing.
• Answering general inquiries about healthcare options under the new Affordable Care Act
• Excellent experience in developing and executing Test Procedures, Test Cases, Test Scripts, Test Plans, performing Functional Testing, Compatibility Testing, Usability Testing, Stress Testing,UAT.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Scrum and Agile

TECHNICAL SKILLS:

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Software: MS Office Suite(Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Mainframe: COBOL, DB2, JCL, CICS, MVS

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint

PROFESSIONAL EXPERIENCE:

Confidential, Saint Charles, MD

EDI Analyst/Business Analyst

Responsibilities:

• Built an Information Security Risk Assessment (ISRA) for the secure exchange of health insurance data as part of the Affordable Care Act (ACA).
• Responsible for implementing payers onto the Health Care Exchange (HIX) for the Affordable Care Act.
• Strong working knowledge of the 834, 837 & 835 EDI Healthcare files and Transactions.
• Compile, validate and report system-wide metrics to attest meaningful use of EHR to the Centers for Medicare andMedicaidServices.
• Created, altered and implemented T-SQL Stored Procedures for the use of processing consumer data and developing new web delivered tools.
• Responsible forUATproject planning like creating testing scenario, test plans, and test scripts.
• 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.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Lead SCHIP, CMS request to be able to identify the Medicare eligible candidates.
• Perform responsibilities of conducting research on IT requirements and business requirements in UATareas.
• Responsible for support and enhancement requests for a SQL data warehouse and transactional database.
• Performed Regression,UAT, Integration, User Interface, GUI, and Usability Testing and wrote test cases and test scripts, execute test scripts and analyzed outcomes.
• Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for bothHL7ADT interface and the application.
• Generated and maintained SQL Scripts to perform back-end testing on the oracle database.
• Produced customer functions, complicate SQL commands in Business Object Enterprise XIR2 and Oracle 10g, Crystal Reports XI environments.
• Assist clients in resolving billing issues for Medicare,Medicaid, and private insurance.
• Involved in creating sample mappings for the conversion of EDI x12 transactions code sets.
• Coordinated with QA teams in the execution of User Acceptance Testing (UAT)
• Acted as an SME on various subject areas including state reporting, death benefits, Medicare, Bill review and RX eligibility.
• Lead projects to design a state-customized Financial Management solution for Health Insurance Exchange (HIX).
• Involved in HIPAA/EDI Medical claims analysis, design, implementation and documentation.
• Developed various test cases for testing HIPAA 8371/P/D 834/835 and 276/277.
• Ensured that the Pre-UATactivity is performed accurately and efficiently.
• DevelopedUATtest process and monitored SIT execution phases.
• Troubleshoot EDI and XML document errors and troubleshoot translation and mapping errors.
• Developed EDI specifications and applications structures for data feeds and mappings for integration between various systems, including XML and performed back-end testing on the Oracle database by writing SQL queries
• Handle the tasks of helping the organization staff in planning data sets forUAT.

Confidential, Detroit, MI

Sr. Business Analyst/Data Analyst

Responsibilities:

• Managed Project scope, milestones, risks and user acceptance tests with internal and external stakeholders.
• Conducted meetings with users and other stakeholders to elicit, organize and document the requirements and also created project status reports and feasibility reports for stakeholders.
• Gathered and analyzed the requirements and converted them intoBusinessRequirement Specifications (BRS) and Functional Requirement Specifications (FRS) for the designers and developers and QA Team to understand them as per their perspective.
• Designed and developed use cases, activity diagrams, and sequence diagrams using Net Beans.
• Extensively facilitated meetings/conference calls with stakeholders, project managers, developers, QA Analysts and other end users based onsite/offshore to deal withbusinessand technical issues and to resolve the issues.
• Created "As-IsBusinessModels" to understand the existing claim settlement process flow through interacting with SMEs, underwriters and Finance department.
• Shared knowledge by performing Impact Analysis on transition from ICD 9 - ICD 10, made suggestions on UI and other changes required to be met during transition.
• Worked intensively with Medicare & Medicaid claims and claims processing for HIPAA 5010 X12 transactions.
• Involved in requirements gathering and preparing the technical system design and System Design analysis of the flow of EDI transaction sets 834, 835, 997.
• Performed Gap Analysis for new functionality requirements, as well as prioritized them based on actualbusinessneeds so as to align them with the product release roadmap.
• Involved in testing the conversion of the application by generating test scenarios in test plan document.
• Validated data at the back-end to ensure that all the Claims related data had been loaded to the corresponding Data Sets in the back-end and the pricing for these Claims was completed as per the Standards.
• Developed HL7 messaging for bi-directional case and disease report exchange, in text and XML formats, in accordance with HL7 specifications
• Analyzed the results, generated reports and tracked the defects using Quality Center.
• Created and maintained the Test and Traceability Matrix.
• Conducted System, Integrated and Regression testing to the application usingBusiness, Functional, User Acceptance and Usability testing.
• Prepared test data in HIPAA compliant X12N format for both inbound and outbound healthcare EDI transactions.
• Trained implementation managers to work on the new application.
• Generated SQL scripts for Development and testing purposes.
• Actively participated in all phases of testing lifecycle (Design, Planning, Development and Results).

Confidential, Milwaukee, WI

Business Analyst

Responsibilities:

• Interacted with Senior Executives and Stake Holders to understand needs and identify key challenges, constraints and risks; thereby define scope.
• Gathered High-Level and Detailed-Level functional and non-functional requirements via daily JAD sessions to define the Business requirements and also created Requirement Traceability Matrix (RTM).
• Created Use-Case documents, UML Diagrams using MS Visio for all functional requirements to help architects, Developers and testing team.
• Coordinate with the development team in making them understand the requirements
• Coordinated the upgrade of Transaction Sets 837 to HIPAA compliance.
• Did gap analysis for HIPAA 4010 EDI 837 and HIPAA 5010 EDI 837.
• Involved in impact analysis of HIPAA 5010 837 transaction sets on different systems in Confidential Health.
• Conducted walkthroughs and participated in defect triage meetings periodically to assess the status of the testing process and discuss areas of disparaging
• Identifying the requirements for accommodating HIPAA 4010 and 5010 standards for EDI X12 transactions
• Collaborated with testing teams in reviewing test strategy, test plans and test scripts.
• Performed UAT Testing with QA and Business Team.
• Performed data validation using SQL queries.
• Managed and controlled the project documentation using SharePoint
• Ensured the timely delivery of Business Analyst team artifacts.
• Participated and Facilitated Status meeting, Business Requirement Elicitation and Solution meetings

Business Analyst / Data Analyst

Responsibilities:

• Worked on Hospital data processing for improving database for storing user files.
• Analyzed business needs, created and developed new functionality to meet real time data integration that facilitated decision.
• Active involvement in ETL design for data integration and master data management.
• Worked with SQL queries for data manipulations.
• Performed duties of a Scrum Master and led the team to produce quality software on schedule using Agile principles and practices. Facilitated daily stand up meetings.
• Used INVEST model to write user stories &Planning Poker, Relative valuation to estimate user stories.
• Prepared Test cases & Managed Requirement churn by incorporating changes to product backlog.
• Created Entity relationship diagrams for the proposed database.
• Participated in the development and creation of the data warehouse.
• Assisted in building a business analysis process model using Rational Rose, Requisite Pro and Visio.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams.
• Involved in User Acceptance Testing along with Business User