SUMMARY

• Dynamic and result - oriented Business Analyst with 9 years of experience in delivering business, technical and systems solutions for the health care industry with excellent technical and leadership skills.
• Extensive experience in gathering business requirement elicitation/gathering techniques like interviewing, questionnaires, brainstorming, focus groups; Facilitating JAD and JRP sessions, User Stories. (BRD) translating them into technical specifications and functional requirements (FRS).
• EDI Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/270/271 processes of EDI Medical Claims Industry from the Provider/Payer side.
• Excellent knowledge of all the phases of the Software Development Life Cycle (SDLC), Test development life cycle (TDLC), Project Management life cycle (PMLC).
• EDI/HIPAA health information and health care services regulatory environment working knowledge and compliance experience.
• Experience in HIPAA 5010 and 4010 transactions as well as ICD9/ ICD 10.
• Experience working on Provider data management like Provider attributes for Individuals vs. Hospitals.
• Adept in creating Business Process Models, Data Flow Diagrams using UML modeling tools like MS Visio.
• Excellent knowledge of different Software methodologies such as Waterfall methodology, Rational Unified Process (RUP) and Agile/ Scrum methodology.
• Working experience as Software Quality Assurance. Experience in creating Test Plans, Test Procedures, Test Cases, Test Scripts, Requirement Traceability Matrix, identifying different Testing Techniques, identifying and tracking defects and conducted Manual and automated testing.
• Experience in performing SWOT analysis, Root Cause analysis, Cost Benefit analysis, GAP analysis and project planning and scheduling.
• Involved in projects which used Data Mapping and Data Conversion tools.
• Proficient in SQL and PL/SQL Programming for testing database integrity.
• Worked with Pharmacy NCPDP EDI standards Version 5.1 and D.0 claims for Medicare and Medicaid process.
• Experience working with Prescription benefit Manager (PBM) which provides cost effective drug distribution and claim processing for payers.
• Worked with Troop & Drug Spend and other adjustment financial calculationsadjusted by the PEGA applications for Medicare claims. Experience with PegaWorkListand WorkBasket functionalities
• Worked with a team of Subject Matter Experts (SME), Project Managers, Developers and QA analysts during the SDLC.
• Well experienced with the offshore-onsite IT services model.
• Complete SDLC experience from development to post production support. Expertise in writing Test Plans and Test Cases.
• Strong team building, time management, meeting management skills and a good team player with excellent written and oral communication skills and can write for technical and non-technical audiences

TECHNICAL SKILLS

Business Tools: Microsoft Office Suite (Word, Excel, Power point, Access, Project and Outlook), MS Visio, MS Project, Rational Suite, PEGA 5.5/6.1, Requisite Pro, Optimal Trace, Caliber RM, Caliber RMD.

Test Automation: Quick Test Pro

Test Management: Mercury Test Director, Quality Center, IBM Rational Clear Case, Clear Quest, Load Runner

Process Methodology: SDLC, RUP, Waterfall and Agile/Scrum frameworks

Others: In-house, TIBCO (BW 5.8 BC 5.6), NASCO, FACETS v4.7.1, v4.8.

Databases: SQL Server 2000, Oracle 10g, MySQL, MS-Access and DB2

Operating Systems: Windows 2003 Server, 2000, NT, XP, 95 / 98, UNIX

Web Servers: IIS 5.0/4.0, MTS, Personal Web Server

Languages: J2EE( JSP, Servlets, EJB, JDBC), Java, C

ETL Tool: Informatica 8.6

Reporting Tool: OBIEE 10.1.3.3.3

EDI Mapping Tools: EDIFECS, Claredi Classic

PROFESSIONAL EXPERIENCE

Confidential, NJ

Lead Technical Business Analyst

Responsibilities:

• Worked extensively on 'Provider Network Organization' (PNO), a Horizon system which stores New Jersey Provider data.
• One of the lead analyst in Provider Network Organization (PNO) 5.3 to 9.0 migration project. Involved in remodeling and feasibility assessment for some of the feeds and Interfaces and downstreams that were impacted as part of the PNO migration.
• Authored Business Requirement Documents (BRD), User Stories, Use Cases, Functional Specification Documents (FSD), UAT documents, Technical Requirement Documents (TRD), RTM for all the impacted systems due to the PNO migration.
• Experience working on redesigning the Feeds and Interfaces for iCore, CareCore, Informatics, HLGS, ITS provider management projects for downstream system impacts through a new Integrated Data Store (Master Data Management).
• Measured risks/impacts for technical and business challenges for remodeled Materialized views and load process including file transfers, direct loads etc. These include data extracts and implementing existing or new transformation rules for existing Feeds using WEB SERVICES and FILE TRANSFERS.
• Extensive gap analysis between Integrated Data Store and Legacy systems for specific Interfaces for the Provider data. Performed analysis of data feed requirements for new products.
• Responsible for coordinating among various teams and clients to ensure accurate migration of data by creating Data Mapping Document and created roadmap for transition from current state to future state.
• Participated in various projects like Value Based Network(VBN) and Horizon HealthCare Innovations(HHI) in their charter and requirements sessions as a Provider SME and documented various FRD and TRD documents for the same.
• Worked on projects involving DATA MODELLING concepts and transformed the business requirements into technical requirements.
• Work with clients, business owners, program managers, and with development team, to refine product requirements, create necessary impact analysis, project estimates, and technical specifications.
• Improved QA deliverables and processes by developing coherent QA strategy and planning, optimizing resource utilization, standardizing specifications, and developing re-usable automation framework.

Confidential, NJ

Sr Business Analyst

Responsibilities:

• Worked on numerous projects as a lead analyst and was primarily involved in the chartering and analysis phases of the project.
• Facilitated all the meeting with the key player in order to run a JAD session to analyze and gather requirements.
• Authored BRD /FRD documents in a use case format via Micro focus Optimal Trace tool (v 5.4).
• Responsible for writing and reviewing the BRD/FRD documents, 'As-Is' / 'To-Be' Process flows with the Core team, Business owners, SMEs and all required signatories.
• Conducted various Cross functional reviews and Review Records required to support CMMI level 3 environments and improvement of the SDLC (Software Delivery Life Cycle) process.
• Developed various Quality phase gate documents and familiar with the CMMI SDLC process.
• Worked extensively on subrogation project for Medicare Part D to ensure Confidential complies with CMS guidance by creating a recovery/reconciliation process in NCPDP EDI standards Version 5.1/D.0 environment.
• Involved in various complex custom client requirements for new capabilities and product enhancements to compete in the marketplace and will be critical to retention and new business.
• As a part of new product design, worked extensively on custom Member Eligibility requirements to clients like Confidential, BCBS Michigan, Duke, Chevron etc.
• Key scribe in various critical analysis discussions on enhancement, compliance and new product design projects under Confidential PDP and BOB.
• Was responsible in gathering the requirements for Client front end applications, Customer services applications and also on custom reports posted to Client websites.
• Worked with NCPDP 5.1 and D.0 Mail/Retail/direct claims, 835 transaction claims.
• As Lead Analyst was involved in various projects which includes Adjustments of Claims a critical analysis
• Responsible for managing the change controls, worked closely with development and testing teams to estimate the impact within a strict delivery dates.
• Identified and vetted requirements for financial (Billing, Pricing, Invoicing) projects, Member website projects, Project involving enhancement of Drug Utilization review, Explanation of Benefits (EOB), Audit processes and Adjustments in PEGA environment.
• Familiar with working with documents in SharePoint, write queries in SQL, Coordinate testing team via Quality Center.

Confidential, PA

Sr Business Analyst / QA Coordinator

Responsibilities:

• Worked with Business Users, technical teams in getting the sign-offs for BRDs, FRDs.
• Conducted JAD sessions, structured interviews, one on one gathering session in order to understand custom client requirements while implementing the 5010 analysis for their 837 and 835 transactions
• Responsible for the entire walk through for Functional Specs to development team and QA team.
• HIPAA I/P, 835 CIS enhancements were prime focus of this project.
• Responsible for conducting daily touch point meetings for HIPAA 5010 project with business, development and testing teams in this Agile/scrum environment.
• Involved in converting to 5010 and creating test data for QA team for 5010 HIPAA 837I/P Claims, 835 transactions.
• Analyzed customer needs and existing functions in the area of HIPAA 4010/5010 Claims to determine feasibility, consistency with the established scope of work.
• Designed and developed use cases, activity diagrams and sequence diagrams.
• Worked with Various Line of Business (LOB) Like AHA (AmeriHealth), Medicare Crossover, Planmate, MHS etc.
• Worked intensively with Medicare & Medicaid claims for transactions.
• Performedrequirements gap analysisand linked QC requirement to test scripts.
• Key signatory for test scripts, User acceptance testing and extensively worked on 5010 data.
• Experience working with Mainframe environment like TCO and ISO for Provider verification data.
• Responsible for Manual testing various claims and logged defects using Defect Module in Quality Center.
• Assisted testing team in understanding the business rules and system development.
• Conducted training sessions for better understanding, operability for the new claim processing system called CIS.

Confidential, Cleveland, OH

Business Analyst

Responsibilities:

• Worked with Business users and technical lead for gathering requirements and data transaction information.
• Created Questionnaire Document and Work Agenda before the JAD sessions.
• Conducted JAD Sessions periodically with various stakeholders at various phases of the Software Development Life Cycle (SDLC) to discuss open issues and resolve them.
• Created the business process model using MS Visio for SME’s for validation and getting the sign-offs
• Gathered and analyzed requirements for documenting reports which spotlights payer’s performance.
• Identified Claims management work flows, business rules and developed flow charts and activity diagrams
• Experience working with the EDI transaction sets 835, 837, 270/271, 278 which include Referrals/Specialty Care Claims.
• Involved in the Payer Cycle such as in the enrollment, CCMS memberships, benefits management claims processing, provider servicing, and member servicing and ad-hoc reporting.
• Worked in a team for Claims processing and was involved in prioritized claims, identified problems, prepared an action plan, implemented the solution, identified claims outside the benchmark
• Data conversion of all EDI claims from 4010 ANSI to 5010.
• Created 5010 preferences for all the HIPAA real time & batch transactions.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Extracting special Claims to test for MSP( Medicare secondary payer)
• Provided Support services for Centers for Medicare and Medicaid Services (CMS)
• Configured FACETS to adhere to customers work flow for claims processing, claims automation and group administration
• Used FACETS to provide seamless transactions between the provider, members and the plan and used FACETS Workflow to route the claims according to the priority.
• Responsible for monitoring the Production Batch jobs for data loading via Information ETL tool.
• Familiarity with Informatica Workflow Manager and Monitor Applications, Informatica Designer applications
• Extensively worked with Data modelling teams for capturing requirements for Database design for developing Datamarts.
• Involved in writing use cases for medical, pharmacy and vision claims as part of Health Statements.
• Developed requirements in designing dashboards for healthcare membership programs to meet the real needs of customers.
• Documented technical details in the functional including data source, file formats and data mapping.
• Documented System Design Documentation (SDD) describing the systems requirement, operating environment, files and database design, input format, output layout, detailed design.
• Assisted the project manager in writing business cases, to verify that this financial tool meets the needs of the business.
• Conducted manual testing and logged defects using Clear Quest. Assisted testing team in understanding the business rules and system development. Created users and user groups to assist testers.
• Used SQL for back end testing and ensured the data is updated accordingly.
• Developed test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Involved in Automated Testing using QTP.

Confidential, Bethesda, MD

Business Analyst

Responsibilities:

• Responsible to insure that EDI Process is HIPAA (Health Insurance portability and Accountability) compliant and worked on ANSI X12 standards.
• Analyzed URS and Functional Requirements Specifications to understand business rules of application.
• Identified the scenarios based on business requirement and HIPAA compliance for each transaction such as 837(Claim) and 276/277 (Claim Status).
• Gathered business requirements through JAD sessions and one-on-one interviews with the Business Stakeholders
• Established project plans, resource allocation, and task assignments for assigned project areas.
• Linked requirements to use cases in Optimal trace.
• Used prototypes to demonstrate and verify the behavior of the system.
• Created class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives
• Created and maintained improvement matrix which was subjected to discussion among the steering committee members for post application deployment in production.
• Generated activity diagrams and developed design specific constraints such as interface type or security level using optimal trace.
• Developed all operational and technical flows using MS Visio and involved in the creation of Business Architecture Document to provide an overview of different aspects of the application.
• Performed data analysis and converted member IDs (PID) to alternate member IDs for all of the MS Access databases used by Claims system.
• Experience working with Nasco Adjudication Processing system. Was responsible for claims routing in Nasco System. Worked with Client Eligibility Module, Pricing, Utilization Review and COB processing
• Involved in Nasco File Edits validation of data in a sequence that ensures the legitimacy of the system edits to follow.
• Processed Medicare claims and worked on EHR as a web based application.
• Mapped EHR records to flat files from various vendors.
• Performed Data mapping, logical data modeling and used SQL queries to filter data within the database tables.
• Involved in Data Selection for testing the EDI Load Process: backend process for loading and processing the data received through EDI and manual process as per Business Rules.
• Preparation of Traceability matrix.
• Participated in Testing using SQL queries on SQL Server tables and generating ad-hoc reports to ensure data integrity.
• Performed UAT testing with client and supported all phases of testing with QA team and managers
• Facilitated and co-coordinated all User Acceptance Testing activities

Confidential, Salt Lake City, UT

Business Analyst

Responsibilities:

• Developed and executed strategic initiatives and programs to enhance existing and Medicare claims processing functions in support of corporate initiatives and requirements.
• Working knowledge in ICD 9 ANSI Health codes HL7 in the claims environment for inpatients and outpatients, reviewed the implementation of the changes made in the systems as per the formats and compliance for EDI usage.
• Used EPIC software for tracking and updating the claim report project and provided guidance in the investigation and final disposition of complex claim matters from Executive Senior Management through JAD sessions for analysis and design.
• Used the RUP methodology and related processes for software re-engineering process. Monitored claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and departmental goals.
• Involved in writing USE cases and prepared the Business Requirements Documents for various requirements collected from the business users. Used MS Visio and UML for generating class diagrams and activity diagrams.
• Wrote requirement document for Data Extraction, Data Analysis and Loading process of collected data as a part of data mapping procedures.

Confidential, Portland, OR

Business Analyst

Responsibilities:

• Expertise in creating Business Domain Model, interviewing SME (Subject Matter Experts) and requirement elicitation.
• Created “As-Is Business Models” to understand the existing claim settlement process flow through interacting with SMEs, underwriters and Finance department.
• Interacted with business owners, users and stakeholders to identify business needs, evaluated solutions for business problems.
• Worked on Pre-pricing process Subscriber/member eligibility, Plan benefits, Check against limits etc.
• Understood Member benefit summary, coinsurance, deductibles, claims processing, HIPAA and other Health insurance related concepts, to devise solutions for better customer experience.
• Experienced with ANSI X12 real-Time EDI 270/271, 834, 276/277,837, 835.
• Conducted JAD sessions to allow different stakeholders to communicate with each other, resolve problems at early stage.
• Worked as a team with other analysts to design detailed analytical models and to create Use Cases.
• Analyzed and documented functional requirements, Use case documents, Requirement traceability Matrix, non-functional requirements, Test Plan and Test cases.
• Designed and developed Use Case Diagrams, Activity Diagrams, and Data Flow diagrams to define the Business Process.