SUMMARY

• Expert in all phases of Requirement Management, including gathering, analyzing, tracking requirements and quality assurance.
• Was a part of a team supporting all phases of the design, development and implementation of an Enrollment Resolution and Reconciliation process for health insurance exchanges.
• Participate in design sessions, report on project progress and identify potential risks and issues.
• Strong Knowledge on claim processing and EDI transactions me.e. Claims Inquiry and Response (276/277), Receipt and Verification of claim forms (837), Claim Payment and advice (835), Eligibility Inquiry and Response (270/271), Certification Request and Response (278), Benefit Enrollment (834), Order and Payment Remittance (820), Functional Acnoledgement (997/999).
• Responsible for analysis of discrepancies in the eligibility reconciliation process for multiple stakeholders and continuous process improvement of the reconciliation process.
• Experience using Health Rules and EDI Transactions (278, 834, 835, 837, and 820
• Provide content toand for collaboration with training staffon training stakeholders on the transactions and the reconciliation process.
• Provided training on the transactions and on the reconciliation processes.
• Experience with enrollment transactions.
• Expertise to design Business Requirement Specification (BRD), System Requirement Specification (SRS), User Requirement Specification (URS), Use Cases Document, Work Breakdown Document (WBD), and Requirement Traceability Matrix (RTM)
• Project management experience
• Strong written and oral communication skills.
• Strong noledge on HIPAA standards, ICD9/ICD10, EDI transactions & 4010/5010 versions, Medicare and Medicaid Services.
• Performed various types of testing like Functional Testing, Unit testing, Integration Testing, System Testing, Performance Testing, Regression Testing, User Experience with premium payment transactions
• Experience in reconciliation of enrollment transactions
• Knowledge of X12 standards development processes
• Excellent communication and writing skills and adept at facilitating walkthrough and training sessions.

TECHNICAL SKILLS

Business Tools: MS Office Suite, MS Visio, MS Project, MS Access, SharePoint

Business Skills: Requirement elicitation, Documentation, Quality assurance

Methodologies: Waterfall, Agile

Database Tools: Oracle SQL Developer, SQL Server

Test Management Tools: Quality center, QTP

PROFESSIONAL EXPERIENCE

Confidential, McLean, VA

EDI Business Analyst

Responsibilities:

• As an EDI Analyst was a part of a team supported all phases of the design, development and implementation of an Enrollment Resolution and Reconciliation process for health insurance exchanges.
• Participated in design sessions, reported on project progress and identified potential risks and issues.
• Was responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges and performed root cause analysis.
• Was also responsible for analysis of discrepancies in the eligibility reconciliation process for multiple stakeholders and continuous process improvement of the reconciliation process.
• Provided content to and for collaboration with training staff on training stakeholders on the transactions and the reconciliation process.
• Provided training on the transactions and on the reconciliation processes.
• Participated in all phases of testing.
• Performed testing and thoroughly documented issues.
• Worked with the technical and development team to resolve identified issues in a timely manner.
• Reviewed documented training material for accuracy and assisted in end user training and support.
• Became a subject matter expert for members of my team.
• Processed cases of a reduced caseload while mentoring team members, by applying triage, research, collaboration and technical noledge.
• Defined and documented business processes and team guidelines for best practices.
• Troubleshooted and resolved errors identified during processing of casework.
• Coached team members for performance improvement and adherence to policies.
• Escalated issues to reduce risk of interruption to production and quality of work.
• Conducted transaction data mapping for gap analysis and conducted testing and implementation of healthcare systems.
• Provided day - to-day guidance to team members.
• Completed assigned casework.
• Provided mentoring to team members.
• Served as a subject matter expert
• Assumed lead responsibilities in the lead’s absence.
• Performed additional duties as they were assigned by Manager and Lead.

Environment: MS Office, EDI, Direct Access, VPN, File Zilla, HICS Access, Lync, Skype, Go to Meeting.

Confidential, Bronx, NY

EDI Business Analyst/Quality Analyst

Responsibilities:

• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus for BRD and FRD and business docs.
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
• Involved in the testing of web portal of New MMIS system
• Acted as a liaison and conducted meetings, JAD sessions and presentations with the teams
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Eligibility. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.me.D), 997 and 999 to identify key data set elements for designated record set. Interacted with Eligibility, Payments and Enrollment hence analyzing and documenting related business processes.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 837, and HIPAA EDI Transactions across enterprise.
• Initiated with a comparison report of migration of . 270 Eligibility, Coverage or Benefit Inquiry (V4010X092A1) vs. 270 Eligibility, Coverage or Benefit Inquiry (V5010X279), 278 Prior Authorizations.
• Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277, 278,820, 837P, 837I, 837D, 835 remittances)
• Used General equivalence Mappings (GEM) to convert ICD9 to ICD10.
• Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with Use Cases from the analysis.
• Wrote Test scenarios and test cases for testing the migration of EDI and the processing of member enrollment and benefits, batch jobs corresponding to the claims (837) and real time transactions like 270/271/276/277.
• Worked with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD9 to ICD10 and backward mapping from ICD10 to ICD9 using General equivalence Mappings (GEM).
• Performed Gap Analysis for HIPAA P and 835 transactions and HIPAA P and 835 transactions.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems.
• 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) .
• Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.
• Assisted in Regression Test, System Test, and UAT.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.

Environment: MMIS, UAT, ORACLE, MS SQL Server, MS office, MS Visio, Quality Center, Water Fall, Facets

Confidential, Detroit, MI

EDI Analyst/ Business Systems Analyst

Responsibilities:

• Involved in discussion with subject matter experts during gap analysis sessions to identify the areas of impact toGateway, Backend Systems and Front end Systems for the 5010 remediation.
• Conducted gap analysis and impact analysisof transition from HIPAA 4010 to HIPAA 5010 on EDI transactions 837 (me, P & D) 1, 834, and 835.
• Conducted and facilitated interviews, user meetings,JAD sessions, and Requirement Elicitation Sessions to extract the Business Requirements related to the upgrading
• Constructed the Business Requirement Document and the Functional Requirement Document for Inbound (837-me, P, D, 270, and 834) and Outbound (835, 271) transactions.
• Worked closely withTrading Partnersto ensure dat requirements were met.
• Contributed in the writing of5010 Implementation, Companion Guides for all ANSI X12transactions.
• Appointed as the point of contact in theHIPAA 5010core team for responding to any queries.
• Involved concurrently in enhancement of HIPAA X124010transaction to HIPAA X125010andICD 9-CM (Clinical modification)toICD-10-CM/PCS(Clinical modification/procedure coding system).
• Performed impact analysis for conversion ofICD-10.
• Used GEM for forward and backward mapping to convert ICD 9 codes to ICD 10 codes and vice versa.
• Reviewing all codes and appropriately applying them.
• Assist in preparing the context diagram.
• CreatedEDImapping guidelines.
• Determined technical parameters forEDI by working with the development team for communication, security, and privacy.
• Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 835, 837-(me, P, & D), 835.
• Acnoledged HIPAA rules and regulations duringElectronic Data Interchange (EDI) and also ensured dat the development team kept up with it.
• Used MS Project regularly to monitor activities, schedules and communication during the project.

Environment: MS Office, EDI, Agile, SQL server, .NET, JAVA, COBOL, MS Visio, HP Quality Center

Confidential, Little Rock, AR

EDI Business Analyst

Responsibilities:

• Collected weekly status reports to ensure dat all deliverables are met on time and on schedule.
• ConductedJAD sessionwith management, senior management executives, and other stakeholders for open and pending issues on the development of the project.
• CreatedUse Casesfrom the list of requirements and prepared use case diagrams using Rational Rose.
• Conducted Web Meetings with Off-Shore team members to ensure dat everybody is on the same page.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to followANSI X12 4010formats including270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter,to meet andexceed HIPAA requirements set forth by the federal government.
• Extracted theBusinessRequirementsfrom the Business Users and documented it for the developers following theHIPAA guidelines by conductingJADsessions and Interviews.
• Worked Extensively with Inbound837I and837 P and835(Out bounds) claims processing systems
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language (PL/SQL).
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Developed schemas for extraction, transaction, and loading (ETL) using Solonde Warehouse Workbench to expedite data integration between systems.
• Worked with various teams and data-architects to come up with processes in dev/qa/prod for Extraction, Transformation and Loading data into the Datamarts.
• Hands on experience in Data Manipulation, Defining Components and in writing SQL queries

Environment: .Net,MS Visio, MS Project, UML Modeling tool, Microsoft Word, Microsoft Excel, Microsoft PowerPoint,Rational Requisite Pro, Rational Rose, Quality Center, and Window XP.

Confidential, Philadelphia, PA

Business Analyst

Responsibilities:

• Maintained clear understanding of project goals among stakeholders by conducting walkthroughs and meetings involving various leads from BA, Development, QA and Technical Support teams.
• Facilitated Joint Application Development (JAD) Sessions for communication and managed Net Meetings.
• Conducted meeting with the EDI team and other stakeholders team members to discuss the requirements.
• Prepared gap analysis document for each transaction.
• Analyzed “AS IS” and “TO BE” scenarios, designed new process flows and documented the business process and various business scenarios.
• Wrote use cases and relevant UML diagrams such as Use Cases, Activity and Sequence diagrams.
• Wrote high level and low level business requirements for the project.
• Developed and conducted statewideHIPAA 5010 and ICD-10 awareness program for all AMFC staff in the Philadelphia Campus.
• Worked on analysis of FACETS claims processing system and gatheird requirements to comply with HIPAA 5010 requirements.
• Analyzed HIPAA 4010 and HIPAA 5010 standards for 837I/P, 27x’s and 835 transactions and
• Presented the process improvement solutions to the client, performed Project Management Office (PMO) activities.
• Worked closely with the business team, development team and the quality assurance team to ensure dat requirements are understood as intended in order to achieve the desired output..
• Participating in all facets of the standard project life cycle and ensured smooth transition of projects to production support
• Involved in creating mappings for the conversion ofEDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.

Environment: SQL, Oracle, Quality Center, HTML, MS Office, Visio