PROFESSIONAL SUMMARY:

• Over 7+ years of experience as a Business/EDI Analyst wif strong analytical and problem - solving skills, maintain excellent interpersonal communication while working on long, complex and tedious assignments.
• Extensive knowledge of Software Development Life Cycle SDLC including Enterprise Analysis, Requirements Planning, Elicitation, Analysis, Communication, Solution Assessment and Validation of Projects.
• Worked on various methodologies such as Agile Software Development, Rapid Application Development RAD, Joint Application Design JAD and Prototyping.
• Create, Review and Analysis of Business Requirement Documents BRDs, Functional Specification Documents FSDs, Use Case Documents, Business Rules Spreadsheets BRS and Standard Operating Procedures SOPs.
• Extensive knowledge of Medical Management Information Systems MMIS, Medicare, Medicaid and National Provider Identification NPI.
• Excellent knowledge of Health Insurance Portability Accountability Act HIPAA standards, Electronic Data Interchange EDI, Implementation
• TEMPEffectively used Rational Requisite Pro to organize, track and change requirements of teh system.
• Expertise of UML in visualizing and documenting teh artifacts using Use Cases, Use Case Diagrams, Activity diagrams, Class diagrams, Data Flow Diagrams, Business Flow Diagrams, Sequence D

PROFESSIONAL EXPERIENCE:

Confidential

Senior Business Analyst

Responsibilities:

• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up - to-date list of payer contacts. Experience on all phases of Software Development Life Cycle (SDLC) from project initiation to deployment. Experience in Agile and Scrum methodology. Assisted JAD sessions to identify teh business flows and determine whether any current or proposed systems in SOA are impacted by teh EDI X12 Transaction, XML, XSLT, Code set and Identifier aspects of HIPAA. Involved in GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Good Understanding of teh EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets. Involved in teh User Acceptance testing UAT to check teh reliability for end users. Designed Test Plans and Test Cases for User Acceptance testing (UAT) wif teh halp of QA teams.
• Strong HIPAA EDI 4010 and 5010 and ICD-9 and ICD-10 processes for member, payers, providers including Coordination of benefits, Co-pays, benefits and etc. Create Mapping documents, ETL technical specifications and various documents related to data migration. Participating in HEDIS performance reporting and intervention analysis.
• Has proven business insight and teh technical know-how to implement large-scale EMR and EHR engagements Worked on teh EDI 834-file load to Facets through MMS ( maintenance sub-system) Worked wif FACETS edits processing. ICD 9 - ICD 10 Conversion Project
• Worked in teh analysis of teh ICD 9 - 10 codes conversion Project. Documented teh Requirement Traceability Matrix (RTM) for tracing teh Test Cases and requirements in Blueprint. Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Modified and created vendor specific maps for teh 850, 820, 834, 855 and 856 transactions (EDI to XML, XML to EDI and delimited to XML). Worked on XSLT, XML schemas and xpath. Developed and prepared EDI documentation for 837 outbound EDS claim processing. Worked on HIPAA Transactions and Code Sets Standards according to teh test scenarios such as 270/271, 276/277,837/835 transactions. Coordinated wif teh EDI team in developing and documenting teh detailed testing work plans and created teh various testing documents for teh assigned EDI transactions. Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers. Created Requirement Traceability Matrix (RTM), Defect Report and Weekly Status Report. Tested teh HIPPA EDI, 834, 270/271, 276/277, 820, 837/835 transactions according to test scenarios and verify teh data wif Facets on different modules.

Confidential

Business Analyst

Responsibilities:

• Gather Business Requirements from teh Business users, Subject Matter Experts (SMEs) and document teh requirements in teh BRD. Involved in gathering, documenting and verifying business requirements. Organized JAD Sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system. Gatheird Business Requirements from teh Subject Matter Experts (SMEs) and documented teh requirements in teh BRD. Worked on documentation for various Care Management Case Referral
• Reasons including, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Physician referral, Primary Care Provider (PCP) referral, internal patient profiling and ICD screening. Develop, coordinate and support Information Technology Division on all operational requirements of FACETS claims processing system and production management. Develop, design & implement department plan to operationalize new FACETS integrated processing system, to include but not limited to, workflow, management oversight and performance analysis. Involved in HIPAA lifecycle wif traceability analysis, mapping, implementation, & also worked on different EDI X12 transactions. Identified end to end requirements for all systems and business units that may be impacted by teh project. Developed requirements integrating Use Case diagrams and designed teh testing process flows. Established and maintained traceability matrix until business requirements were signed off. Conducted walkthrough and lead work sessions. Using MS - Visio analysed business requirements and process through Use Cases, Class, Sequence, and Activity diagrams, and adapted UML standards to define modularized Data Process Models. Ensured
• Use-Cases were consistent and covered all aspects of teh Requirements document. Developed a Business Acceptance testing strategy and plan. Created test files and analysed test results using MS-Excel. Involved in Claim Processing from End to End and major work was involved wif 837 P/me Claims
• Processing systems. Worked as system analyst on System Support, data migration and data, meta-data validation. Worked on Claims Processing and Claims Accumulation and Adjudication in FACETS. Involved end to end testing of FACETS Billing, Claim Processing and Subscriber/Member module. Set claim processing data to test different Prior Authorization to use in teh claims. Worked wif Defects and involved in Defect Triage and prioritization.

Confidential

Business Analyst

Responsibilities:

• Utilized Rational Unified Process RUP to configure and develop process, standards and procedures. Conducted JAD sessions wif business units and stakeholders to define project scope, to identify teh business flows and determine whether any current or proposed systems are impacted by teh new development efforts. Prepared teh Business Requirement Document BRD and Functional Requirement Document FRD for teh enhancement of teh existing services. Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance. Requirements
• Gathering Analysis to ensure HIPAA Compliance Auditing. Created Test Scripts, Test Plans, Validation Plans and Testing Metrics Reports. Performed Functional, Integration and Regression Testing. Analysis of inbound and outbound interfaces and extensions to TriZetto FACETS Claims Processing system.
• Worked in FACETS Reconfiguration of member/subscriber, Data Element Definition and Usage wif values and Completed configuring FACETS Applications like Related Entity, Parent Group, Group, and Subgroup using IVSTech Data Toolset. Configured teh Billing Module that includes fee rate, premium rate, and invoices. Analysed data and created reports for all issued Action Items. Completed Data Mapping for group and detailed product analysis and report writing. Extensive backend testing using SQL queries, generating teh reports to ensure teh data integrity and validate teh business rules. Participated in solving Billing issues from teh FACETS Problem Log for TriZetto and Billing Entities. Analysis and Design of teh TriZetto FACETS Data Model to ensure optimal system performance and tuning. Involved in bug tracking and defect prevention activity, configuration management and UAT. Involved in performing GAP analysis and highlighted related issues. Involved in various phases of SDLC throughout teh project life cycle in Rational Unified Process RUP environment and teh creation of artefacts and managed various roles specified by RUP.

Confidential

Business Analyst

Responsibilities:

• Created and revised Business Requirement document BRD and Functional requirement Document FRD using teh Scope and Interview wif stakeholders. TEMPEffectively implemented Claim possessing accounts and provided support for its smooth operation. Researched teh existing client processes and guided teh team in aligning wif teh HIPAA rules and regulations for teh claims systems for all teh transaction sets. Worked wif different functional groups to arrive at teh common business and technical specifications. Wrote SQL statements to extract data from teh Tables Upgraded HMO Medicare EDI and reporting.
• Participated in JAD sessions and interacted wif various functional leads and analysts. Participated in risk sessions to address teh risks and addressed project impacts to bring to light teh possible workaround. Worked in an Agile environment. Conducted HIPAA report analysis to bring out teh identified structure reports and documented it. Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose. Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling. Performed detailed comparative analysis of response to RFPs of vendors and Graphically Represented teh recommended solutions in
• PowerPoint to Senior Management. Performed manual front - end testing to check all functionalities of different modules. Helped in Deployment of Portal a venue for teh on-line trading application a Collaboration Bundle Solution. Ensured that teh application met user and management expectations. Suggested measures and recommendations to improve teh application performance. Designed and created Excel sheets to provide market analysis charts.