- Confidential has 6+ years of experience in business process analysis, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare
- Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
- Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans). Strong knowledge of managed care payer requirements and procedures.
- Expertise in Business Process Modeling, Business Process Re-design and in designing Process Architecture.
- Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
- Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML), Object Modeling Technique (OMT), Extreme Programming (XP), and Object Oriented Analysis (OOA).
- Experience in writing SQL queries and optimizing the queries in Sybase, Oracle and SQL Server 2000.
- Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
- Good understanding of MITA and MMIS functional business areas which include claims, provider’s services, provider’s enrollment, recipient services etc.
- Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking
- Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
- Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills. Hands on experience as an expert user of MS Excel, MS PowerPoint, MS Access, Business Objects.
- Strong knowledge of managed Claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems,
- Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.
Functional Specification Design
Testing (Test Cases) (Manual & Automated Quality Assurance (QA)
Documenting Process Flow
Business Contingency/ Business Continuity Planning
Rational Team Test
Load Runner and Test Director
SQL Server and MS Access
MS Project 2002
Adobe workflow systems
Mercury Quality Center
Senior Business Analyst
- Helped in defining Change Management Process for Release Management Team.
- Researched, defined and deploy BI improvement opportunities and streamline the business intelligence processes
- Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
- Responsible for providing BI support and ensuring high levels of availability in the Business Intelligence environment.
- Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
- Identified gaps in the business process.
- Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
- 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.
- Developed and maintain information and documentation related to developing and modifying business processes and systems.
- Gathered requirements from users of the Clear Quest (CQ) tool for any Enhancements or change requests for any defects.
- Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and Use Case Narrative using the UML (Unified Modeling Language) methodologies.
- Led and conducted JAD sessions for requirements gathering, analysis and design of the system.
- Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using rational tools.
- Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
- Established RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
Environment: Rational Rose and Requisite Pro, MS Visio, MS Project, UML, Agile, XML, Windows XP, NT/2000, HTML, SQL SERVER, Vignette Content management Tool, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9 i
Confidential, Buffalo, NY
- Worked with a team to help Confidential prepare for affordable care act to receive HIPAA 820 files to receive payments for Annual premium tax credit, Cost share reduction and Risk reinsurance and adjustments from Health and human services and/or State exchange..
- As a Business Analyst Worked on the Claims processing system within the company for scanning and capturing of data including working on UB-92 claims forms. Involved in using the technology to recognize, validate, and store claims and their attachments using HIPAA compliance interface.
- Prepared logical data model in the form of Business Context diagram to include various entities and attributes in order to facilitate the design of Data model in the form of ER Diagrams. Studied current information structures and data models of the current databases to better understand the design of target data source.
- Performed custom data conversions and developed custom software for risk management applications including general claims, vehicle accident and administrative tracking. Performed all data field mappings.
- Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
- Used Rational Clear Quest to track required changes and Rational Clear Case to maintain different versions of the project documentation. Responsible for developing, managing and enhancing the data warehouse and business intelligence solution
- Followed a methodical Change Management Process and documented any Change Requests into Clear Case for any changes in the requirements after the requirements were base lined.
- Prepared Test Cases based on base-lined Requirements Document, prepared Requirements Traceability Matrix and provided Performance Testing Requirements. Worked very closely with the Test team to Test all iterations during the Testing Phase and documented all the defects.
- Medicare and Medicaid Insurance Billing, Hl7 Standards, HIPAA, EDI, HEDIS 834, 835,837, Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, ICD 10, Electronic Health Records, Electronic Medical Records.
- Substantial report development experience utilizing SQL Server Reporting Services, Cognos Impromptu, and MS Excel
- Facilitated the User Acceptance Testing (UAT) with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
- Prepared training materials in the form of User manuals by preparing step-by-step guide to all screen flows in CMS.
Environment: Rational Suite (Rose, Requisite Pro), Rational Unified Process (RUP),ICD, Agile, Windows NT/XP/2000, UML, UNIX, MS-Project, MS-Office Suite, MS Visio, Mercury, WinRunner, Test Director
Confidential, Nashville, TN
Environment: MS Visio, SDLC, UML, SQL SERVER, Rational Clear Quest, Rational Clear Case, Rational Tools Suite, AGILE methodology, Windows, XML, HTML, Facets.
- Involved in HIPAA/EDI Medical Claims, Design and Documentation
- Monitor and Analyzed activity report and transaction monitoring.
- Creating document and diagrams for membership enrollment according to HIPAA 834 compliance standard for membership enrollment. Checked inbound/outbound HIPPA regulated EDI transactions facets
- Created various database objects like views, tables, and procedures to extract data and support the end user reportingdata ware houserequirements. Conduct meeting with the development team to discuss any requirement changes.
- Wrote standard and complex SQL queries using MS SQL Server and also in Mainframe for data validation process.
- Prepared BRDs (Business Requirement Documents) supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze and document business data requirements fromData ware house. Performed GAP analysis of business rules, business and system process
- Worked on solving the errors of EDI 834 load to Facets through MMIS.
- The project involves creation of custom tables, developing custom forms to load data into the custom tables and creation of a XML report to compare sales values against the data in oracle. The custom tables are populated from a third partydata ware houseon a regular basis. Performed Data Analysis using procedures and functions in PL/SQL.
- Designed Activity, Sequence and process flow diagrams using MS Visio to simplify and elaborate certain selection and filter condition. Documented requirement using Use Case analysis