CAREER SYNOPSIS

• A competent professional with 9 years of extensive experience in business analysis in Healthcare Insurance domain and MMIS system. Expert in clarifying business requirements, performing gap analysis between goals and existing procedures/skill sets, and designing process and system improvements to increase productivity and reduce costs. Strong business analysis skills and an understanding of the Software Development Life Cycle SDLC utilizing Rational Unified Process RUP . Experienced in working on Medicare and Medicaid benefits in accordance with Federal Regulations.
• Good understanding of gap analysis, requirements management, risk analysis and project plans. Adept in creating and updating Business Requirement Documents and Functional Requirement Documents. Lead JAD sessions and act as the lead facilitator for various projects from start to finish through the SDLC. Strong interpersonal skills, highly adept at diplomatically facilitating discussions and negotiations with stakeholders.

TECHNICAL SKILLS

Business Skills

Business Process Analysis Design, Gap Analysis, Impact Analysis, Data Modeling, JAD/JRP Sessions Requirement Gathering, Customer Liaison, Requirement Extraction and Documentation, and Use Case Modeling

Methodologies

SDLC - Agile and Waterfall

Languages

PL/SQL, HTML and XML

Databases

DB2, SAS, MS SQL Server

Operating Systems

Windows Vista, Windows 95/2000/XP/7, and MS-DOS

Microsoft tools

MS Office Suite Word, Excel, Power Point, Outlook, MS SharePoint, MS Visio, and MS Project

KEY SKILLS

• Extensive success in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language UML .
• Proficient in gathering business and technical requirements from both formal and informal sessions utilizing a variety of software tools including.
• Extensive experience in conducting Joint Application Development JAD sessions.
• Supported FMEAs Failure, Mode, Effect and Analysis sessions
• Performed gap analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Proficiency in creating Business Process Modeling including Use Cases, Activity Diagrams, Data flow diagrams and sequence diagrams using UML, in MS Visio and Rational Rose.
• Extensively used MS office, clear case and share point.
• Expert in claims reporting, claims processing lifecycle and insurer's unique identifier number.
• Extensively worked with subject matter expert SME on the claims reports and other statistics reports.

Worked on Implementation of MMIS Health Enterprise System for different states.

• Worked on complete online mediation and real time claims processing system of Inpatient claims, Outpatient claims dental claims, disability, pharmacy claims, Medicare crossover claims and transportation claims.
• Extensive knowledge of NASCO, FACETS, and HIPPA healthcare applications.
• Experience with HIPAA versions 4010 and 5010 and the impact on backend and front end systems and applications as well as ANSI X12 Health Insurance Transactions and payers 837/835/834/ 820/270/271/276/277/997/999 .
• Knowledge on Prime Dental and Prime Pharma in claims processing system.
• Knowledge on NCPDP provider identification number and worked on enrollment of provider in the MMIS system.
• Strong knowledge of applied principle of the iterative methodologies of SDLC including Requirements Analysis/Design and Development as per the Rational Unified Process RUP . Documented Business Requirements, Functional Specifications and Detail Design of the Application.
• Extensive knowledge in implementing new MMIS compared to old MMIS.
• Solid technical knowledge on data warehousing, operational systems optimization with online transaction processing OLTP and database normalization, entity relationship, reporting and online analytical processing OLAP .
• Solid understanding of BABOK, use cases, sequence diagrams, collaboration diagrams, activity diagrams, and class diagrams.

EMPLOYMENT HISTORY

Confidential

• Implementation of MMIS Health Enterprise HE System: Implementation of Medicaid Management information System MMIS Health Enterprise HE a complete online mediation and real time claims processing system of inpatient, outpatient, dental, pharmacy, disability, Medicare and transportation. Xerox has successfully implemented multimillion dollars projects in several states and received CMS Certification for Medicaid programs. The focus of the project was the transformation of old Legacy system to Health Enterprise System that required Business, Functional, technical services related to System analysis.
• Updated functional design specification documents DSD with reference to the new change request CR from the client.
• Worked on adding a new member and provider as an internal user in the enterprise system UAT ENV and validated the data according to the system specifications.
• Extensively worked on Health Insurance HIPAA transaction codes specifically on health care payer and EDI and 834 to in corporate partial, modification and enhancements requirements in by capturing data and mapping it to the existing system.
• Worked with different functional teams Provider, Member, Benefit Plan, Claims Pricing, Claims Adjudication, Claims Front End, Claims Payments and Financials, Service or Prior Authorization SA or PA, THIRD Party Liability TPL, Reports and Letters and Pharmacy.
• Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions
• Claims entering, validating and submitting process as an external provider by using provider web portal as well as internally as a state authorized user.
• Worked on claims batch jobs, claims reporting, claims processing lifecycle.
• Extensively worked with subject matter experts SME's on the claims reports and other statistics reports.
• Executed the quires and checked the database whether the new added member and provider are stored in data base tables.
• Successfully conducted Requirements Validation sessions and JAD sessions with the State staff of North Dakota, Alaska and effectively meet all requirements requested for the North Dakota and Alaska MMIS.
• Accountable for writing, overseeing, and delivering the formal Requirements Validation Documents and Requirements Traceability Matrices RTM for Provider, Member and Claims Front End for the ND-MMIS received sign-off from the State on these Requirements Validation Document deliverables.
• Lead and created solutions in the Iteration Design and Development sessions and demo sessions associated with the agile approach to design and development of the NY-MMIS
• Created concept session documents and user stories according to client requirements and presented to the SCRUM team and implementation team.
• Documented necessary system modifications on an ongoing basis developed test plans, test case scenarios, and test scripts to insure functionality based on the modification.
• Worked on adding a new Member and Provider in the UAT and SIT ENV and validated the data replication from MMIS to OS Pharmacy System . Worked on adding the TPL coverage to the member in MMIS UAT and SIT ENV and validated the data in the data base tables.
• Validated and tested Provider and Member data in the UAT and SIT ENV and created the defects in clear quest CQ and assigned the defects to different functional teams.
• Worked on MMIS and OS pharmacy database mapping and validated the data in the OS pharmacy system through the GG replication process.
• Extensively worked on parallel testing. Validated the claims data from MMIS Legacy system to new Health Enterprise HE system by comparing member information, Benefit Plan, Pricing, Exception Codes, Taxonomy Codes, Procedure codes, Diagnosis related group DRG codes, Service Authorization, Benefit Limits, and Service allowed units, Category of eligibility, Claim Header Level and Line Level Information.
• Extensively worked with system development team and created user stories and test cases according to the client requirement.
• Created internal and external change requests CRs in Clear Quest CQ according to the client requirements. Worked on the defects and CR's by coordinating with different functional SME's and development leads.
• Added new business rules in the ReqPro by using business rule catalog. Extensively worked on CR tracing by tagging the use cases in ReqPro.

Environment: MS Office Suite Word, Excel, Power Point, Visio, Project, Access, Share Point, RequisitePro, Rational Doors, JIRA, Clear Quest, SQL.

Business Systems Analyst

Confidential

Project Description:

Clearing house is fully automated, real-time claims processing system for complete, on-line mediation of medical, dental, vision, and disability claims following HIPAA guidelines. The system facilitates the efficient and timely management of all health care insurance relevant data - clinical, financial, and administrative throughout the organization enabling the sharing of health information between the sub systems.

Responsibilities:

• Analyzed Business Requirements, developed, tracked and enhanced them into functional requirements using Rational Requisite Pro as a requirements tool.
• Extensively worked on Agile methodology in software development life cycle and web application development.
• Presented client requirement to project team members through clear project plan presentation.
• Worked on Health Insurance HIPAA transaction codes specifically on health care payer and EDI 277 and 834 to in corporate enhancements to existing efforts on capturing and mapping.
• Interacted with the ICD-10 transition team and participated in JAD/JAR sessions.
• Provided business and technical consulting services for ICD-10 remediation and other concurrent business requirements as a result of the ICD-10 implementation, mandated by the centers of Medicaid services.
• Worked with NASCO implementation and claim processing team.
• Analyzed the business requirement as per the ACA HIPAA rules and regulations to follow in creating business requirement documents.
• Worked with FMLA and disability Claims department, determined the direction of LTD and STD claims and analyzed a variety of criteria to determine eligibility of benefits. Evaluating claimants degree of physical/mental limitation based on medical records and clinical review recommendations. Coordinated with clients like insureds, doctors, hospitals, attorneys and other individuals as required.
• Develop and maintain risk management policies and procedures to maintain regulatory compliance while minimizing and stabilizing the total cost of risk.
• Researched, evaluated and make recommendations regarding current and state-of-the-art trends in risk management/safety/loss prevention, risk financing and claims management.
• Assisted in review of potential acquisitions to identify significant risk management and insurance issues and make recommendations.
• Continuous supervision of project to analyze implementation of client requirement through Requirement Traceability Matrix RTM .
• Documented the meeting minutes from the JAD's and stored the artifacts in the appropriate place holders and SharePoint for both the teams to review.
• Developed business required documents BRD on the basis of JAD sessions for project.
• Worked in GAP analysis to understand the difference between both the billing systems and documented the GAPs in GAP analysis spreadsheet.
• Created Used Case Diagram and Activity Diagram to provide better understanding of process to developers and other team members.
• Developed Change Request Form to satisfy client requirement changes and created.
• Documented the business requirements into functional requirements document.
• Gathered requirements and transformed them into high-level Process-Flow

Business Analyst

Confidential

Project Description: This project dealt with developing and implementing new web based system at the dental hospital and integrating it with the stand alone medical information system at the hospital. The project was about developing new application so as to comply with HIPPA 5010 and EDI 837 with ICD-9 codes. Also, it involved dealing with the billing and registration system.

Responsibilities:

• Interacted with the business user and IT team for understanding the requirements.
• Worked with business representatives to understand data requirements and priorities and ensure that IT work is appropriately aligned
• Created Business Requirements and converted them into System Requirement Specifications.
• Worked on SCRUM Project Management and Agile Methodologies for Software Development Life Cycle
• Played an active and lead role in gathering, analyzing and documenting the Business Requirements and Worked on capturing various client specific requirements as well as CMS Compliance and HCR Regulatory requirements.
• Conducted JAD sessions with business users, stakeholders to understand the requirements in more detail
• Participated in Design walk-through with end users to baseline the business architecture.
• Performed GAP analysis on the existing solution and its transition into the new HIPAA 5010.
• Worked on Prime Dental in claims processing and reporting
• Used Rational Rose to carry out the business modeling and object modeling effort.
• Generated various SQL queries as and whenever required.
• Created data flow and sequence diagrams to describe how EDI Healthcare Transaction set 837 was used to submit health care billing information.
• Involved in preparing a simple and detailed User manual for the application, for an intended user.

Environment: Oracle, PL/SQL, MS Word, MS PowerPoint, MS Access, MS Visio, MS Project, XML files, UML

Business Analyst

Confidential

Project Description: The project involved Replacement of VAS with VISTA reports system that integrates reports of all the products of Hartford Life

Responsibilities:

• Worked closely with Scrum masters, designers and developers in Agile environment, and determined solutions by balancing the business needs and technical aspects.
• Worked on Health Insurance HIPAA transaction codes and on implementation of ICD- 9 in accordance to HIPAA compliance.
• Facilitated the definition of project scope through the use of scooping deliverables and ensured traceability of all future deliverables back to scooping
• Modeled functional requirements, converted business requirements into technical specifications using sequence and activity flow diagrams in MS Visio and MS Project.
• Formulated and tested queries with SQL, created and documented test plans and cases efficiently.
• Developed test cases for selected modules, manually tested application modules and used Test Director for generating reports, tracking defects and testing performance.
• Participated in the testing phases including development of test conditions, scenarios, test plans, expected results and testing execution.
• Modified and refurbished Data Requirement Impact Analysis to make it applicable and compatible for the designers architect, as well as end users. Environment: Oracle Warehouse Builder, MS Visio, MS Project, Use-Cases, MS Excel, MS Access, SQL Server, Windows XP.