- Overall six plus years of experience as a Business Analyst in Healthcare insurance domain.
- Expertise in complete Software Development Life Cycle (SDLC). Also well versed with
- Change Request and Change Control Management required in SDLC. Commanding knowledge of various development methodologies like Waterfall, Agile/ Scrum.
- Extensive experience in gathering, managing and documenting business and functional requirements, and creating Business Requirement Document (BRD), Functional Specification Documentation (FSD),Solution Requirements Business Use Cases, Functional Use Cases and User stories.
- Extensive experience working with CMS regulations and HIPAA guidelines. Worked with FACETS edits and EDI HIPAA Claims processing. Knowledge of EDI Claims, member enrollment, and billing transactions.
- Knowledge of Electronic Health Record (EHR), EDI transactions, ASC X12 Transactions like 270/271, 276/277, 835, 837I and 837. Experience in installing, configuring, managing, monitoring and troubleshooting SQL Server.
- Development of various financial and general reports out of Oracle using SQL.
- Strong knowledge of the Software Development Life Cycle methodologies (phases and gates) like Agile and Waterfall models. Analyze financial information including operating statements and net worth statements to determine appropriate loan size, terms, and pricing.
- Adept at creating and transforming business requirements into functional requirements and designing business models using Unified Modeling Language (UML) diagrams, Sequence, Activity diagrams and Class diagrams.
- Experience in conducting Joint Application Development (JAD) sessions, Q&A sessions, and personal interviews; analyzed the outcome of these sessions and well - understood requirements; proposed alternative tasks; estimated time, budget and scope of the project
Databases: Oracle, MS Access, SQL Server2012, DB2, Sybase
Modeling Tools: Rational Rose, MS Visio, Bizagi Modeler, UMLet
Change Management: Clear Case, SharePoint, Doors, RequisitePro, StarTeam
BI Tools: Business Objects, Tableau 9.1, Advanced Excel, Power Pivot
Testing Tools: HP ALM, Quality Center, Dynatrace, PerfMon, Selenium IDE
Database Tools: SQLPlus, TOAD, SQL Developer, Workbench
Defect Tracking Tools: Rational Clear Quest, HP Quality Center, ALM
Operating Systems: iOS, Windows Server 2012, Ubuntu, Linux
Confidential - Woonsocket, RI
- Gathered business requirements by participating in JAD sessions, interviewing business users and SAs and also ensured the Change request for the BRD when identified the requirements which were out of scope after the SRP sessions.
- Designed Business solutions and Business requirements.
- Utilized the existing Client Hierarchy; Daily Claims Feed schedules, and Real Time process knowledge base for building a sound migration plan and create Rationalization (justification) Reports for JAA and JRA sessions.
- Areas of responsibility included Paper Claims,BenefitEdits (especially Drug Edits and Process Plan Options). Worked on Medicare - Payer reconciliation.
- Converted the Functional Requirements (FRs) into Process Flow Diagrams and Wireframes. Reviewed Technical Requirements Document ("TRD") as first intra-gate pass. Conducted the internal SME reviews for TRDs, and UATs.
- Coordinated with the requirement analysis team to finalize the scope of the project.
- Created and updated the Functional Documents including Business Requirement Document (BRD), Functional Specification Document (FSD), Requirement Traceability Matrix (RTM),
- Created and maintained Work Flow diagrams including Activity Diagrams, Class Diagrams, and Sequence Diagrams, Data Flow Diagrams using MS Visio.
- Used framework to drive requirements, process flow documents, and subsequent design estimation. Used Query Analyzer, Execution Plan to optimize SQL Queries.
- Created Wireframes and UI Mockup Screens using MS Visio and MS Office.
- Maintained document repository for SharePoint to ensure that any change to the system documents is communicated effectively to the entire team and business users in a timely manner.
Environment: UML, MS Visio, IRCS Common Membership, CICS, WebSphere M/B, EDI, HIPAA 5010, Medicare, Medicaid, LIS, Quality Center, Oracle9, DB2, Mainframe, PBM, PIMS, SQL Developer..
Confidential - Louisville, KY
- Gathered business requirements and provided efficient and cost-effective solutions around FACETS system.
- Facilitated and worked as a liaison between different members to develop the application.
- Assessed "as-is" process required for gap analysis through user interviews, data collection and analysis, design and evaluation of "to-be" process solutions
- Created data mapping documents based on client specifications which involved working with Facet claims, membership & plan data model.
- Tested the Facets system through EDI transactions mainly on 837 Professional and Institutional Claims enrolment.
- Created mapping for EDI transactions, specially 837, 820 and 834 and outlined the updated processes for Members enrolment, Eligibility, and Premium Payment Transactions.
- Review and understand the claims enrolment process and complex requirements for the enhancement of the current system created under the Requirement Specification Documents.
- Applied the SQL scripts to the test database and execution of the scripts on the database.
- Responsible for analyzing pending claims in dispute using Facets.
- Planned and defined system requirements to Wireframe with Use Case, Use Case Scenario and Use Case Narrative using the UML methodologies; designed and developed Use Cases.
- Used SQL to query SQL Server databases for data analysis and documentation of data flow and data processes.
- Used Facets for various health insurance areas through EDI 837, such as enrolment, member, Products and other Facets related modules
- Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions; provided programming and support for claims processing functions and auto-adjudication.
- Performed Data mapping, logical data modeling; created class diagrams and Entity Relationship diagrams using MS Visio and used SQL queries to filter data.
Environment: Requisite Pro, Rational BPM, Agile, HL7Interfaces, PL/SQL, HTML, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML, RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.
EDI Business Analyst
- Facilitated sessions to collect User Requirements and Business Requirements
- Business/User/Functional/Technical Requirement Specification using MS Project, MS Word and MS Visio that provided appropriate scope of work for technical team to develop prototype of the overall system
- Created Use Cases, various UML Diagrams and Data Flow Diagrams to determine the data flow via various systems
- Proposed the change and reengineering of the 'AS IS' Business processes into the 'TO BE' process flow. Involved in the day-to-day implementation of the Agile methodology of application development with its various work flows, artifacts and activities.
- Produced for transaction sets 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements, as well as prepared mapping documents ensuring the upgraded application included the required changes and additions for 5010 compliancy.
- Tracking and addressing the problems on timely manner encountered on Acknowledgement 997, Claim Status Inquiry/Response 276/277, Remittance Advice 835, Eligibility Inquiry/Response 270/271, Prior Authorization 278 claims.
- Gathered requirements from the administrative staff and business rules for determining member eligibility and successfully converted them into functional requirements for the developments team.
- Have played a role of Project Manager in the absence of assigned project Manager and have lead monthly/Quarterly review sessions on project status with Vice President - PMO
- Responsible for resource planning, cost benefit analysis and risk analysis and present the same to senior management.
- Able to take a large conceptual problem or project, break it into components, establish plans and a critical path, achieve incremental goals and deliver project on time and at or below budget.
- Created web Page mock ups for clients using wireframes. Developed and maintained the Requirement Traceability Matrix (RTM) for the project deliverables using Rational Requirements Composer
- Analyzed if the system abides HIPAA regulations as portal displays member's private information.
- Reviewed and approve technical recommendations related to software and hardware proposals from technical team.
- Participated in leading and executing user acceptance test scripts.
- Assisted BI developer to build and maintain SQL queries for data extraction and analysis
- Assisted in designing test plans, test scenarios and test cases for integration, regression and UAT to improve overall quality of the Application. Validated FTE saves through hypothesis generation and implemented corrective measures for time, labor and cost reduction. Involved in configuration of FACETS Subscriber/Member application.
- Worked on FACETS Data tables and created audit reports using queries. Manually loaded data in FACETS and have good knowledge on FACETS business rules. Responsible for conducting user Acceptance Testing (UAT).
- Conducted meetings with cross functional teams and ensured that project deliverables and milestones were met.
- Interviewed businesses to extract their requirements for the system.
- Provided recommendations for achieving Productivity improvement based on statistical data analysis and data validation.
Environment: MS Office Suite, SQL Server, Agile/SCRUM, PL/SQL, UAT, MS Visio, SharePoint, UML, Oracle, MS Project.
Confidential, Long Beach, CA
- Created business Process Workflow Diagrams and Activity Diagrams in Rational Rose.
- Conducted GAP analysis to derive requirements for existing systems enhancements and created workflows and business process flows to highlight the changes
- Developed functional specs, gathered requirements and communicated with the developers. Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and 271.
- Designed Work Breakdown Structures (WBS) to comply with the triple constraint: time, cost and scope.
- Coordinated the documentation of business requirements and scoping of requirements for this phase, across multiple business functional areas.
- Created the Technical Specification Document, which involved project scope, ETL architectural diagram, Functional and non-functional requirements, assumption, constraints, dependencies and risk of the project.
- Audited and analyzed front end medical billing issues. Communicated with clients regarding verification of patient demographics and insurance information, making updates accordingly. Researched missing information in order to complete the billing process.
- Performed Requirement Analysis and developed Use Cases using Visio; and created Use Case Specification Documents (USD). Efficient in MS Project/MS Excel for planning/status reporting/writing test scenarios.
- Worked on HIPAA standard/EDI Standard Transactions: 834,835,837 to identify the key data set elements to the designated record set. Collaborated with the Claims, Payment and Enrollment Team in analyzing and documenting the process.
- Extensive work with various Rational tools like RequisitePro- Requirement gathering/maintenance, Use Case document maintenance, Rational Rose for Use case diagrams, Sequence diagrams and activity diagrams.
- Worked on Member Management, Eligibility, Claims and Billing modules within FACETS.
- Creating Unified Modeling Language (UML) diagrams such as Use Case Diagrams, Activity Diagrams, Class Diagrams, navigational flows, story boards, UI specifications and Sequence Diagrams.