PROFESSIONAL SUMMARY:

• Dynamic and result-oriented Business Analyst with 8 years of experience in delivering business, technical and systems solutions for the health care industry with excellent technical and leadership skills.
• Strong expertise in Health Insurance Claim process, Medicaid and Finance.
• Excellent knowledge of all the phases of the Software Development Life Cycle SDLC , Test development life cycle TDLC , Project Management life cycle PMLC .
• Good analytical and problem solving skills coupled with creativity and can-do attitude.
• Experience working in Medicare and Medicaid projects.
• Excellent knowledge of HIPPA Health insurance Portability and Accountability Act transaction codes such as 835 payment and remittance Advice 837 health care claim / 834 benefit enrollment /270/271 inquire/response health care benefit processes of EDI Medical Claims Industry from the Provider/Payer side.
• Well versed with HIPAA, Facets, claim adjustments, claim processing , ICD9/ ICD 10 from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Effective in Facilitating Joint Application Development JAD/JAR/RAD sessions for gather, synthesize and prioritize requirements using interviews, document analysis, requirements workshop, site visits, and surveys..
• Extensive experience in gathering Business/Functional user requirements, creating Use Cases as per user requirements, developing/designing diagrams such as Activity, Class, and or Sequence diagrams, and in addition to creating Business Requirements Document BRD .Translating BRD into technical specifications and functional requirements FRS .
• 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 Agile/ Scrum methodology.
• Experience in performing SWOT analysis, Root Cause analysis, Cost Benefit analysis, GAP analysis and project planning and scheduling.
• Experience in User Acceptance Testing, Smoke Testing, Regression Testing Performance Testing and Functional Testing ensuring successful implementation of the requirements.
• Experience in conducting GAP Analysis , SWOT Analysis ,Risk Analysis and cost/benefit Analysis.
• Experience in developing GUI, working together with developers and end-users to perfect the end-users requirements.
• Excellent Business writing skills in writing project documentation such as: Business Requirements Document BRD , Functional Requirement Document FRD , and Use Case Specifications.
• Experience in writing quires/ Scripts for Data Analysis using SQL and PL/SQL .
• Ability to work both independently and in cross-functional team environments manages and prioritizes multiple projects, quick learner.

TECHNICAL SKILLS

PROJECT DESCRIPTION

Responsibilities:

• Worked on numerous projects and served as primary and/or sole BSA from initiation to deployment phases of the projects.
• Plan sessions with Business, SMEs and required stakeholders to confirm business requirements. .
• 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.
• Creation of workflow diagrams to document current and future business environment
• Track progress of projects to ensure alignment to requirements manage any deviations from requirements to ensure resolution.
• Prepared Maintained Requirement Traceability Matrix RTM to ensure traceability between documented requirements and test cases.
• Served as a point of contact for requirements clarifications and defect resolutions amongst various technology vendor teams both on-shore and off-shore.
• Co-ordinate with the project managers in the preparation of the project plans with any impact due to a change request.
• Involved in implementation of HIPAA EDI Transactions 835,837
• Facilitated Electronic Data Interchange.
• Performed GAP Analysis for HIPAA 4010 and 5010 transactions.
• Used EDI tools to verify mapping to X12 format.
• Developed various gate documents to comply with ePMO process for sign-offs.
• Analyze HIPAA EDI transactions in X12 responses and of 837, 835, 277CA and 999 and looked for defects.
• Review test plans and scripts for completeness and accuracy. Determine operational objectives by capturing business and technical requirements.
• Participating in QA team meeting and bug tracking meetings and Prioritized outstanding defects and systems problems, ensuring accuracy and deadlines were met.
• Working with ACA for Horizon Medical Billing and Revenue Cycle Management .
• Collected requirements for Pharmacy Benefit Management and Medicare part D programs .
• Was responsible in gathering the requirements for Client front end applications and Customer services applications both via portal and IVR.
• Responsible for managing the change controls, worked closely with development and testing teams to estimate the impact within a strict delivery dates.

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 .
• 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 CIGNA 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 Coventry, BCBS Michigan, Duke, Chevron etc.
• Key scribe in various critical analysis discussions on enhancement, compliance and new product design projects under CIGNA 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..
• 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.
• In depth knowledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors.

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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.
• Recommend changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• HIPAA 5010 837I/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 4010 x12 to 5010 and creating test data for QA team for 5010 HIPAA 837I/P Claims, 835 transactions.
• Worked with Various Line of Business LOB Like AHA AmeriHealth , Medicare Crossover, Planmate, MHS etc.
• Worked intensively with Medicare Medicaid claims for 5010 X12 transactions.
• 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.
• Used rational Rose to create UML diagrams such as use case, activity, sequence, class and component diagrams..
• Conducted training sessions for better understanding, operability for the new claim processing system called CIS.

Responsibilities

• Worked with Business users and technical lead for gathering requirements and data transaction information.
• Gathered and analyzed requirements for documenting reports which spotlights payer's performance.
• 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
• 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.
• Extensively worked with Data modelling teams for capturing requirements for Database design for developing Datamarts.
• Coordinated with QA team on writing use cases for medical, pharmacy and vision claims as part of Health Statements.
• 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.
• Involved in Automated Testing using QTP.

Confidential Role: Business Analyst

• Responsible for developing the agenda and leading the requirements gathering sessions.
• Gathered requirements by interviewing the primary stakeholders and SMEs.
• Analyzed and documented functional requirements, Use case documents, Requirement traceability Matrix, non-functional requirements, Test Plan and Test cases.
• Uses tools like Axure to mock up screens for requirements review and sign off.
• Conducted JAD session with developer team and testing team.
• Designed and developed Use Case Diagrams and mock-ups to define the Business Process.
• Coordinating with the development team for bug fixing and coordinating the release schedules.

Confidential Role: Systems Analyst

Description: Objective of this project was to document a detailed DR Plan considering the establishment of a new Disaster Recovery site at Sungaurd. Including information like Readiness Assessment, Inventory, DR Approach, Emergency Protocols, Call tree, Security Policies and Periodic drill requirements.

Confidential

Role: Business Analyst

Description: Entity is the core application used by CMS staff to manage their day-day business by the Wealth Management group. Entity houses the profile of all potential and current client information and their portfolio.

Confidential

Role: Business Analyst

• Description: Calendar application is the core tool used by the account management team for planning campaigns, scheduling portfolio marketing, time tracking and client communication. It also integrates with
• Entity application for client profile information.
• Geo-coder for geo coding feature
• Outlook for appointments.

Confidential

Role: Systems Analyst

• Description: Objective of this project was to document the revised security policy for Desktop
• IT Application Administration for CMS Companies applications and its partner companies
• Data Center Access
• Remote Access VPN
• Mobile Email Access

Confidential

Role: .Net Developer

Description: This is a web enabled wizard based application. Application was geared toward clients of CMS Companies, the objective of the application was to collect and/or confirm information related to taxes and investments. The application also allowed users to provide additional information and generate a summary report as well.