SUMMARY

• A dedicated business analyst over 5+ years of industry experience.
• Hardworking individual with knowledge in all phases of Software Development Life Cycle (SDLC) including requirement gathering, analyzing, designing, developing and testing.
• Ability to work well with other and take actions under pressure dat are teh most appropriate for achieving departmental and organizational goal
• Extensive experience in creating and documenting Business Requirements and System Functional Specifications.
• Result oriented Joint Application Development (JAD) facilitator and meetings coordinator with excellent communication and interpersonal skills.
• Ability to lead system upgrades and implementations for teh department, and provide technical support as needed.
• Knowledge of Business Process definition, Risk Analysis, and Use Case Analysis. Experience working under Agile Scrum and Waterfall methodologies.
• Worked with use cases and UML diagrams
• Strong knowledge of claims management process, Medicaid and Medicare Services, CMS, HIPAA, Compliance Issue
• Strong knowledge of provider data and Credentialing
• Strong knowledge in teh Energy industry with various pricing implementation and method
• Excellent in tracking and maintaining teh changes requested by teh Stakeholders.
• Strong presentation skills and ability to tailor presentations towards different functional areas of business.
• Developed training materials and trained end users on newly developed and existing applications.
• Experienced in all stages of testing.
• Strong experience with health insurance administration systems eligibility, enrollment, underwriting, claims, billing, and payments.
• Strong experience of working with Medicare and Medicaid insurance data, and Insurance Claims.
• Excellent in organizing groups of users based on their designations and functions

TECHNICAL SKILLS

Business Analysis: Waterfall, Agile, RUP, GAP Analysis, Critical Thinking, Decision Making Strategy, Use Case Analysis, Requirement Analysis, Healthcare Domain

Documentation Tools: MS Project 2010, MS Visio, Bugzilla, MS Office Suite, Confidential quality center

Languages: SQL, PL/SQL, XML

Tools: Oracle, MS Office, MS outlook, MS Test Manger, Jira, Confidential QTP

Database: Cactus, MS SQL Server 2012/2008, MS Access, Teradata

Operating Systems: Windows 2000/XP/ Window 7/ Windows 10 Unix, Solaris, Linux

PROFESSIONAL EXPERIENCE

Confidential, Brooklyn, New York

Sr. Operations Analyst

Responsibilities:

• Generated reports to analyze files to ensure data entry procedures
• Created comparisons dat proactively ensured teh accuracy of teh provider directory
• Created standard reports/ dashboards to be shared monthly with management
• Functioned as a subject matter expert for preparation, execution and submission of all regulatory reports (including but not limited to PNDS, HSD tables and Provider Directory Fulfillment)
• Created and maintained Business Requirement Documents (BRD) for each regulatory report for consistency and audit purpose
• Meet all deadlines associated with regulatory reporting with 100% accuracy, including working deficiency and audit purposes
• Maintained Strong and collaborative relationship with State and Federal regulators for purpose of file submission
• Developed and ran extracts to support departmental operational reporting
• Completed ad hoc reporting for all NPO department as needed, such as physician roster requests, county reports, excluded party list, delegated entities, etc.
• Developed standard queries in Cactus so dat teh team can run reports as needed on their own
• Perform ad - hoc data queries and comparison as needed to ensure consistency across systems
• Function as a system subject matter lead expert for CACTUS, Optum Geo Access, Quest Analytics, and Healthrules (Payor)
• Track gaps and opportunities based on provider deficiency Create and implement technical roadman to improve and increase efficiency automation
• Stay current on new functionality, system options and new offerings. Present to management as needed
• Demonstrated thorough understanding of Elderplan’s provider data and maintenance components stored in Cactus & Payor
• Conducted Interviews, user meetings, JAD sessions, and Requirement Elicitation Sessions to extract teh Business Requirements
• Created and published training manual, knowledge transfer documents, and process flows for departmental use
• Performed analysis to audit department operations with a focus on data integrity, improving accuracy, and identifying training opportunities for department

Environment: Cactus, Healthrules Payor, Quest Analytics, Optum, Meditract, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio, Visual Studio), FileZilla

Confidential, Suffern, New York

SR. Project Manager/Business Analyst

Responsibilities:

• Be teh liaison between teh business units, technology teams and support teams.
• Actively engage with internal /external teams to streamline and standardize existing processes by identifying and developing opportunities to increase efficiencies
• Demonstrate ability to solve complex problems and offer creative suggestions for alternative designs and methods
• Evaluate new projects and business challenges and design practical, attainable solutions
• Create business and functional requirement documents, process flows, use cases, and screen mock ups as needed for new projects and system enhancements
• Track and document post implementation benefits and key objective measurement
• Develop and deliver executive-level reports (using SQLand / or Excel) for key strategic initiatives
• TEMPEffectively present information and respond to questions from groups of managers and key internal personnel
• Perform business data analysis and ensure teh quality, consistency, and integrity of data in a timely, TEMPeffective, and reliable manner
• Create tools in excel to help Operations manage day-to-day responsibilities

Environment: Agile, User Stories, Use Cases, MS Share Point, MS SQL Server, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio, Visual Studio), Bugzilla, SnagIt

Confidential, New York

Lead Business System Analyst

Responsibilities:

• Gather requirements from DST Subject Matter Experts to understand and input information to DST PowerStepp.
• Query teh system and pull data for both HCFA and UB Claims file which contains both Paper and Electronic pended claims from Companies 1 through 6 and 8 based on Date range and Percentage.
• Organize JAD sessions to consistently meet DST and Confidential ’ project standards.
• Write well defined epics and implement into user stories
• Create user stories and use cases for software development
• Review and maintain user stories and use cases
• Get sign offs on user stories
• Ensure existing claims workflow functions teh same after conversion to AWD 10 Process Model flows are complete.
• Query system to pull out claims with Hold Codes and re-adjudicate them to verify it is being paid.
• Convert all gatheird information in toDataflow, process flow and use case diagrams.
• Carry outdataanalysis and help in developing validation and verification criteria and test cases
• Verify teh Hold Codes in existing claims and configure it to an Error or Warning.
• Create a template and map Hold Codes to teh most accurate Claim Adjustment Reason Codes (CARC) which is then mapped to similar Remittance Advice Remark Codes (RARC).
• Test Model system claims and configure teh Benefits and verify it is accurate to its respective claim.
• Adjudicate claims after testing teh benefits or UXC and recreate already posted claims.
• Use Edifecs TestManagement tool to upload ICD-9 codes and have it automatically mapped to corresponding ICD-10 codes.
• After verifying teh Benefits in Model, move all tested data to Production.
• Set up/update Provider Contracts based on compensation requirements according to Fee Schedules.
• Process EOB’s and EOP’s based on members and provides request
• Receive ERA’s (Electronic Remittance Advice) from Emdeon/Relay
• Process 835’s and enroll ERA’s in to PowerSTEPP
• Once processed document and track provider information in Spreadsheet
• Send documented ERA enrolled member information to Emdeon/Relay weekly.

Environment: PowerSTEPP, AWD 10, JIRA, Confluence, TestM, Process flows, Claims, Sharepoint, Snagit, .

Confidential, Camp Hill, PA

Business Analyst

Responsibilities:

• Participate with an energetic team on a rapid,agiledevelopment schedule
• Gatheird requirements from stakeholders for provider management and member
• Map data elements to T-MSIS data elements, and identify gaps
• Create use case diagrams for T-MSIS.
• Write detaileduserstorieswith acceptance criteria and reviewing with teh development teams
• Develop Implementation estimates and Project Plan
• Identify any T-MSIS data element sources outside of teh MMIS, where possible
• Identify ETL requirements
• Facilitated JAD sessions for Requirement Validation with Client Dept. of Public Welfare (DPW) to Identify MSIS to T-MSIS conversion requirements
• Translate T-MSIS epics in to user stories
• Create a batch process to extract and format GA MMIS Provider, Managed Care and TPL data to meet teh requirements for teh monthly creation of teh T-MSIS TPL file.
• Use teh CMS approved TPL mapping document in conjunction with teh CMS DED and Data Dictionary Appendices to create a batch process to extract and format teh Provider, Managed Care, and TPL data into files to be loaded to teh T-MSIS database
• Analyzes and documents client's business requirements and processes and communicates these requirements by constructing conceptualdataand processmodels, includingdatadictionaries and volume estimates from organization.
• Use Oracle SQL Server to run queries against teh production data base to gather data elements for mapping conversions
• Used Microsoft SharePoint (PA PROMISe™) as teh version-tracking tool for managing teh requirements documentation.
• Provide advanced problem solving and functional support, and work with teh team to resolve complex functional problems.
• Facilitate and organize in teh creation of teh Provider, Managed Care, and TPL File for T-MSIS
• Create and design test plan and test cases for previous MSIS files consisting of teh Long Term Care file (LT File), Inpatient file (IP File), Pharmacy file (RX File), Other claims file (OT File), and Eligibility file, along with teh new integration of teh Provider File, Managed Care File, and TPL File for T-MSIS
• Pull claim data using PA Production and PA Model Office for testing
• Verified and validated all teh build or release related issues and resolve then through discussion with business analysts with teh users approval.
• Interacted with business heads to finalize teh Business Requirements for teh application

Environment: MS Share Point (PA PROMISe™), Subsystem MAR, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), Oracle SQL Plus, CMS, PA PRODUCTION, PA Model Office, TMS, Doco Tool