SUMMARY

• 8+ years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Experience in Healthcare Application Facets in different modules like Claims, Memebrship, Provider and Billing.
• Extensive knowledge of Software Development Life Cycle (SDLC). Understanding and knowledge of various methodologies like Agile - Scrum,Waterfall, and RUPand Scrum-Waterfall hybrid methodologies.
• Involvement in Data Dimensional Modelling, Data Extraction Transformation Loading (ETL) and Business Intelligence Reporting using Tableau & Informatica.
• Good knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment).
• Extensive experience in conducting Joint Application Development (JAD) sessions for project definition involving analyzing requirements, creating prototypes, user interface, database schema and system design.
• Strong visual modeling and business process modeling skills using Rational Unified Process (RUP) and Agile Unified Process (AUP) with tools like Rational Rose, MS Visio, and well experienced in developing Use Case Models, Entity Relationship Diagrams (ERD), Data Flow Diagrams (DFD), Activity Diagrams, Sequence Diagrams and UML CASE tools.
• Highly proficient in working with users to gather requirements, analyze them and subsequently use the Rational project and design tools to model the requirements.
• Experienced in SQL Server Reporting Service (SSRS), Executing Queries and Running Store Procedures.
• Solid experience with SQL Server and T-SQL in constructing triggers, tables, user functions, views, indexes, user profiles, relational database models, data dictionaries, and data integrity
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Responsible for creating different sessions and workflows to load the data to Data Warehouse using Informatica Workflow Manager.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications

TECHNICAL SKILLS

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

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

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

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 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

PROFESSIONAL EXPERIENCE:

Confidential, Hartford, CT

Sr. Business Analyst

Responsibilities:

• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Gathered detailed business and technical requirements and participate in the definitions of business rules and data standards.
• Acted as a liaison between client and payer/intermediary. Experienced in payer rules, requirements, governmental regulations and HIPAA compliance.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Worked on MITA to upgrade the existing MMIS and also conducted mapping for EDI transactions
• Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
• Managed the systems development and built the business processes to activate Medicare parts A-B-C & D, Special Needs Programs (SNP) and Private Fee For Service (PFFS) plans on FACETS version 4.41 platform.
• Responsible for the use of scarce resources through the development and sharing of reusable software making use of (Medicaid Information Technology Architecture) MITA.
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Gathered the Requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act (PPACA).
• Analyzed Business Requirements (BRD) and translated them into Functional Requirements (FRD or Use Case Model)
• Extensive experience in Data Analysis and ETL Techniques for loading high volumes of data and smooth structural flow of the data.
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Defined Business Process aligns with Company goals and existing HIPAA regulation to communicate with CMS Programmatically from Amisys system.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Facilitated System Integration Testing on FACETS systemtoverify HIPAA compliance from 4010 to 5010.
• Experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, FACETS 4.5/4.7 system, Claims Processing, Insurance Pricing and Claim Adjudication. Strong Experience in FEP (Federal Employment Program) andCDA (Clinical Development Analytics). Healthcare Domain Knowledge with SQL knowledge (in Oracle environment) and 5010, ICD-10 experience.
• Ensured data integrity through effective configuration of fields and tables; proficiently review and correct 837 rejected files as well as evaluate 835 files to determine optimal solutions for creating payor matches.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Preparing BRD, Business Cases, and presentation to the clients, Business Re-engineering proposals.
• Deflected the impact of multiple report requests from the Business Intelligence users.
• Design, develop and went live after migrating several MS Access & SQL Server databases for corporate developers, resolving typical database issues.
• Captured all HIPAA-related EDI data in the repository using FACETS.
• Defined Business Process aligns with Company goals and existing HIPAA regulation to communicate with CMS Programmatically from Amisys system.
• Established traceability matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.

Environment: MS SQL Server, Ascential DataStage, (Designer, Director, Manager, Parallel Extender) Debugger, Oracle, MS Word, Excel, Visio, Access, and Project, Mercury TestDirector Agile, Waterfall.

Confidential, Oakland, CA

Sr. Business Analyst / BI

Responsibilities:

• Offered my experience in Healthcare Payer and Provider Operations, re-engineering claims, benefits, enrollment and eligibility processes.
• Used SQL, Cognos, SSRS, Plexis, EZ Cap, eCW, Sales force for Data and Reporting.
• Used to do data analysis, data validations, data layouts, mapping documents and Manual Testing.
• Used to prepare the Reports like Board Report, HPMS Reports, Encounters Report.
• Connected different data bases by SQL and wrote SQL Queries for viewing and downloading the Metadata and analyzing the data.
• Gathered the requirements for the Business Rules Engine (IBM's iLog) to ensure that the BPM tool uses the correct rules while translating and migrating the Benefits.
• Used Metadata to prepare the Data layouts, Data Mapping (STM) Source to Target Mapping - different layers of mapping.
• Created claim payments test scenarios and claims test data in QAT environment of Health Services.
• Worked on connecting different data bases by SQL and writing SQL Queries for viewing and downloading the Metadata and analyzing the data.
• Generated User Test Case (UTC), Expected Results (ER) and results file by usingMDE (Medical Data Express) Claims Test Pro tool.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Performed System testing of the Claims processing systems (Pricing Rules, Duplicate/Limit validations, Member Eligibility and Provider Enrollment).
• Coordinated defects routing in the team and created Excel macros to generate daily defects report status from Quality Center across multiple teams.
• Analyzed system requirements and developed Test Plans, involved in developing Test Script for manual testing.
• Regression Testing of Web applications and applications dealing with Medicaid and Medicare Services
• Worked on EDI transactions: 270, 271, 834, 835, and 837 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Used Test Director and Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Analyzed and translated business requirements into system specifications utilizing UML.

Environment: Rational Rose, Clear Quest, Microsoft Project, Crystal reports, SharePoint, Mercury, Rules Engine, Lotus Notes, Erwin, Microsoft Visio, Microsoft Office suite, SQL, Business Objects, ETL, Oracle, SSRS, Cognos, EZ Cap.

Confidential, Austin, TX

Business / Data Analyst

Responsibilities:

• Involved in multiple projects, primarily focused on ICD-9 to ICD-10 (in to MMIS/ Mainframe system) Mapping and Modeling Implementation process, claims processing (Medical/Dental), provider and Reimbursement segment. Also, developed cross-walk for understanding major changes from ICD-9 to ICD-10. Provided support through the entire lifecycle for multiple projects involving web service and user interface development, covering Provider, Claims and Reimbursement Processing domains.
• Worked with claims module involving claims search, claim adjustments, data corrections, claim reprocessing.
• Prepared test Data Sets and performed data testing using the PL/SQL scripts. Also used MS Excel for data mining, data cleansing, data mapping, and data dictionary and Data analysis.
• Performed Data analysis and data profiling using complex SQL on various sources systems including Oracle and SQL Server.
• Developed Data Flow, Work Flow, Process Flow, and Entity Relationship Diagrams in MS Visio, and analyzed them to create "AS IS" and "TO BE" scenarios.
• Verified the functional aspect as per the Business Process and validated the interfaces with the other systems and data conversion from the existing system.
• 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 the life-cycle.
• 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
• Developed business and functional requirements for the National Provider Identifier (NPI) Crosswalk and Crossover Claims Crosswalk solution.
• Used SQL for back end testing, data retrieval and data analysis.
• 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.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• 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.
• 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.

Environment: Microsoft Office Suite, Microsoft Visio, ETL, MS Word, MS Access, MS Excel, MS Visio, Windows NT/XPMS Office, JIRA, MS Access, MS SharePoint, MS Project, MS Visio, Rally., SAS, Oracle, SQL, SQL Server.

Confidential, Orlando, FL

Business Analyst

Responsibilities

• Responsible for business analysis, requirement specifications, project planning and identifying the resources and implementation of the project.
• Worked on Claims Processing, Claims Enquiry, Remittance, Payments and Reductions, Eligibility, Accounts for Subscribers, Providers, Members, Payers and Claims Editing.
• Developed the Project using the Iterative RUP model. The Project was streamlined through all phases of the RUP model starting from Inception through Transition. Used a Functional Decomposition strategy to divide system into sub-systems.
• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non-functional requirements.
• UML was extensively used for specifying, constructing and documenting the software system.
• Worked closely on 834 transaction code for Benefit Enrollment and did manual testing using Test Director.
• Involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
• Performed the Gap analyses of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
• Created functional flow diagrams, context diagrams and other high level diagrams for documenting the functionality of separate modules using MS-Visio and UML.
• Developed Class Diagrams, State diagrams and physical Component diagrams/ DFD's to capture the entire system functionality and thereafter built a framework for the software development phase.
• Utilized business and technical tools to develop business and system requirement analyses with supporting variance reports, current and target business process flows and traceability matrices.
• Designed message formats, queues, legacy systems interfaces, and worked with the business Users though interviews and JAD sessions. Created front-end prototypes as deliverables and projected the end-delivery modules.
• Involved in preparing UAT Test Plan and Testing Status Reports Based on Functional Requirements.
• Used Query Analyzer, Execution Plan to optimize SQL Queries
• Prepared requirement specification, functionality trace matrix, quality assurance plan and designed test cases. Communicated with business, technology leadership for overall project/program office milestones.

Environment: Microsoft Office Suite, UML, RUP, MS-Sharepoint, MS-Project 2000, MS-VISIO, CMMI, Quality Center, Windows.