SUMMARY

• Healthcare Business Analyst with 7 years of experience in the HealthCare Industry.
• Knowledge and expertise in working with Claims, Provider Relations, Enrollment, Benefits Administration, and Vendor Relations' Business Areas
• Extensive experience in data analysis and mapping.
• Experience in writing SQL reports - SQL report writing experience with deep knowledge developing complex queries across multiple tables.
• Vendor Management - Worked as a facilitator for Testing Efforts and New Requirements between the Healthcare Company and its various Vendors.
• Worked in projects involving Benefit Base Plan changes and Configuration changes to ensure the accurate processing of claims. Determined dependencies between enrollment and benefits processes and ensured each Business Areas delivered their tasks on the projected target dates.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Experience in Forward Mapping and Backward Mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Expertise in EDI HIPAA 4010 - 5010 Project to convert EDI X12 Healthcare 4010 transactions into 5010 Complaint transactions.
• Good understanding of Health Care Industry claims management process, Medicaid and Medicare Services and insurance sector.
• Implemented various HIPAA codes (270 and 276) used for Billing and Eligibility purposes of patient records.
• Expertise in all the phases of the Software Development Life Cycle (SDLC), Agile Development and RUP methodology. mm
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and Rational Rose using UML concepts.
• In-depth knowledge and extensive experience in FACETS.
• Experienced in building test plans and test cases and navigating through the test lab.

THECHNICAL SKILLS:

Project Methodologies: Rational Unified Process (RUP), UML, Agile, SDLC

Business Modeling Tools: Rational Rose, MS Visio

Requirement Management Tools: Rational RequisitePro, Informatica

Defect Tracking Tools: Rational Clear Quest, Quality Center, Test Director

Operating Systems: Windows NT/XP/2000, UNIX

RDBMS: MS Access, Oracle, SQL Server, TOAD

Quality Assurance Tools: Mercury Quality Test Pro. LOAD Runner, WinRunner

Design Tool: Microsoft Visio, MS Excel

Regulatory Knowledge: HIPPA, SOX

Other tools: XDE/Websphere, COGNOS

PROFESSIONAL EXPERIENCE

Confidential, Boston, MA

Business System Analyst

Responsibilities:

• Prepared the data mapping documents for EOHHS and CMS approval; this includes the Source to Target Map, Addendum A (Additional Criteria), Addendum B (Reasons for not submitting Data Elements), Addendum D (Question and Answer about Encounter data and Eligibility) and Valid Value Crosswalks.
• Prepared the Source To Target Map for Claims Inpatient, Claims Others, and Claims Long Term and Financial Transactions.
• Responsible for Facilitating JAD sessions, taking meeting minutes, creating and reviewing business requirements, functional specification and writing Business Requirement Document.
• Engage HP and CW SMEs to focus on their area of expertise maximizing their time to the project.
• Involved in making a decisions on how to use the data available to meet T-MSIS requirements and how to address gaps in the data available.
• Interpreted in conjunction with the MassHealth, MMIS technical teams and Data Warehouse technical teams, CMS’ T-MSIS data requirements.
• Worked with HP/ EOHHS subject matter experts to provide advice and to facilitate decision making in how to address each data element.
• Document the gaps in data identified in the data mapping process.
• Assisted the testing team in writing test scenarios, test cases and execution.
• Verify the data format, field type, length, cross-walk values and default values for a sampling of each data element for each of the eight (8) files.
• Verify successful transmission of T-MSIS data files via connectivity established currently for MSIS to CMS.
• Validate the eight (8) T-MSIS files sent to CMS adhere to data content and formats defined during the source to target mapping.

Environment: Word, Excel, PowerPoint, Share point, MS Visio, Quality Center, Clear Case, Clear Quest, TFS (Team Foundation Server)

Confidential, OH, Columbus

Business System Analyst

Responsibilities:

• Used ITrace ‘Information Tracking Repository and Collaboration Exchange’ to enter and manage requirements, change orders, system objects, system testing and release information.
• Responsible for Facilitating JAD sessions, taking meeting minutes, creating and reviewing business requirements, functional specification and writing Business Requirement Document.
• Assisted the testing team in writing test scenarios, test cases and execution.
• Assisted with source to target mapping of MITS data to the T-MSIS data as required and documented in the T-MSIS Data Dictionary developed by CMS.
• Assisted in generating all mandated requirements contained within the CMS T-MSIS Data Dictionary.
• Assisted in generating requirements for portion of the eight mandated T-MSIS data files in the standardized formats required by CMS. Eligibility, Provider, Managed Care Plans Long Term Care Claims (LTC), Other Claims (OT), In Patient (IP) and Pharmacy Claims (RX) and Third Party Liability
• Assisted with source to target mapping of MITS data to the T-MSIS data as required and documented in the T-MSIS Data Dictionary developed by CMS
• Provided ongoing feedback to all teams and kept continuous communication with the project manager and upper management to make sure the project completion is going as planned.

Environment: MS Visio, Word, Excel, PowerPoint, Share point, iTRACE, Quality Center, Clear Case, Clear Quest

Confidential, Atlanta, GA

Business System Analyst

Responsibilities:

• Facilitated JAD sessions, which focused on the definition of business requirements associated with Confidential ’s claims process.
• Created Use Cases that defined the role of users who receive claims, users who process claims, and users who adjudicate claims. Used MS Visio to develop UML diagrams
• Used Rational Requisite Pro for documenting requirements gathered from business users.
• Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry (270).
• Utilized EDI Health Care Claim Payment/Advice Transaction Set (835) to make payments, send an explanation of benefits (EOB) remittance from a health insurer to a health care provider.
• Authored data flow diagrams, sequence diagrams, and business process models that describe how the EDI Health Care Claim Transaction set (837) is used to submit health care billing information and encounter.
• Acted as a liaison by working closely with the development and testing team for achieving milestones.
• Collected test metrics weekly from the Clear Quest in RUP suite database that reflected the current status of the test execution and the state of the defects. Used Rational Clear Case for managing the version changes across all stages of the SDLC
• Worked on conversion of 4010 to 5010, 834 compliant transactions.
• Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Claim Processing and Subscriber/Member module.
• Membership/enrollment and billing-entered information on Facets to ensure correct eligibility, etc
• Worked with the technical architect to design security, interaction, and interface of the application. Also worked with architects to create logical and physical data models.
• EDI Health Care Claim Status Request (276) was used as part of the implementation by Confidential to request a status of a health care claim.
• Performed manual testing of the functional items by checking a summary of all claims entered and submitted.

Environment: Rational Requisite Pro, Rational Clear Quest, UML, RUP, MS Visio, SQL Server 2000, MS Office, Windows 2000/XP.

Confidential, Bronx, NY

Business Analyst

Responsibilities:

• Interviews with program staff
• Descriptions of the current MMIS system, interfaces, and business processes elicited during the Joint Application Development (JAD) sessions
• Review of documentation supplied by the Information Technology Department (ITD), the Division of Information Technology (DoIT), and DHS Medical Services staff, and from the Department of Human Services (DHS) website
• Worked with HIPAA Team implementation of X12 ANSI 270/271 and 276/277 Companion guides for Pharmacy and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving 837 HIPAA compliance and 835 Remittance Advice.
• 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)
• Worked closely with Business Directors, project managers, business analysts and SMEs in various business areas to gather, analyze and document the requirements and supported the project throughout the development lifecycle
• Automation of test scripts was done using QTP for test re-usability of different online transaction modules.
• Gathered requirements from users of the Clear Quest (CQ) tool for any Enhancements or change requests for any defects.
• UsedFACETSAnalytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.).
• Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems
• Assisted in Regression Test, System Test, and UAT.
• Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
• Created and maintained the Requirements Traceability Matrix (RTM).
• Created Use-Cases and Requirements documents to document business needs.
• created Process flow diagrams using VISIO
• UsedQuality Centerfor tracking defects, enhancement requests, assign work activities and assess real status of project throughout life cycle.
• Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrollment and benefits, batch jobs corresponding to the claims(837) and real time transactions like 270/271/276/277

Environment: UML 2.0, MS Office Suite, MS SharePoint 2007, MS Exchange Server, ASP.Net, C#, Oracle 10g(SQL and PL/SQL), TOAD, Cognos 8.1, MS Visual Studio Team Server-Test Edition.

Confidential, Durham, NC

Business Analyst

Responsibilities:

• Gathered and documented business requirements from Trading Partners, user groups and vendors via workshops, interviews, and surveys.
• Worked in close collaboration with the Project Manager and business users to gather, analyze, and document the functional requirements for the project.
• Worked in Healthcare Claims Administration Healthcare Claims Processing(837/835) includes facility claims and professional claims
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 4010; 837, 835, 270/271, and others.
• Used the mapping tools to map 4010 and 5010 transactions along with ICD 9 and ICD 10 codes, and validated the HIPAA Syntax.
• EDI Claims Processing - documented enhancements to the EDI Claims Processes (EDI 837, 835, 276, 277) to ensure accurate processing of claims of members.
• Used HIPAA 4010 transactions to support the analysisof current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes forHIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
• Worked with EDI Mercator Team for Data Mapping and Building 837 Maps
• Work in conjunction with IT EDI group to develop standard product offerings with respect to HIPAA transaction sets (837/835).
• Followed Workgroup for Electronic Data Interchange (EDI) standards for testing that need to comply with the HIPAA transaction sets.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Involved in setting up the ADT data for Hospital Billing (HB) team by admitting, discharging, add charge drops and Coding and Abstracting.
• Submitted change requests and worked with change request records in Clear quest.
• Participated in entering, tracking system defects in Rational Clear quest
• Conducted UAT testing writing Test scenarios, test Cases and executed them.

Environment: Rational Requisite Pro, Rational Clear Quest, UML, RUP, MS Visio, SQL Server 2000, MS Office, Windows 2000/XP.

Confidential, Long Island, NY

Business Analyst

Responsibilities:

• Part of the team for migration of HIPAA - EDI X12 4010 series to 5010 series for EDI Transaction code sets:
• Performed GAP analysis of 4010 and 5010 EDI transaction using implementation guide to identify the changes in the segments and data elements.
• Worked with Web Sphere message broker for integration of the applications in SOA.
• Developed Incident documents and portrayed the As-Is reporting structures versus To-be Reporting needs for data integrity and accuracy.
• Identified the scope, business objective and documented the functional requirements for each release.
• Directly involved in process improvement Plans and implementing business change.
• Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and appropriate GUI screenshots.
• Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions
• Created use cases specifications, use case diagrams, swim lane diagrams, component diagram and context diagrams to define the workflow and segregate high-level and low-level requirements using MS Visio.
• Conducted and Participated JAD sessions to gain consensus on various issues related to the project. Acted as a facilitator on different occasions.
• Held regular meetings with the Business users and SME’S to priorities the business Requirements.
• Facilitated the resolution of project-related issues, identified risks, and mitigation steps to manage risk using PLSQL in RDBMS.
• Conducted walkthroughs and code reviews with developers, project managers and stakeholders and users to comprehend business work flow of applications.
• Extensively involved in Database testing by writing SQL queries.
• Used SQL Developer to execute Queries.

Environment: MS-Visio, Pega CM, Windows XP, Oracle, SQL, Facets.

Confidential, Owings Mill, MD

Business Analyst

Responsibilities:

• Facilitated 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.
• Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
• Created Use-Cases and Requirements documents to document business needs and involved in creating use cases based on HIPAA standards.
• Gathered Requirement from the Client to fulfill the Application need for FACET Implementation.
• Created and maintained the Requirements Traceability Matrix (RTM).
• Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
• Refined the requirements (use-cases) and Business Process Models to detailed level appropriate for technical analysis and system design.
• Was responsible for tracking issues that are detected and updating the status of existing issues based on the daily meetings with the off-shore team.
• Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
• Worked Facets Data Models and their relationship between all functional areas.
• Designed and developed new Interfaces based on business requirements and system’s needs.
• Followed Waterfall methodology for the entire SDLC.
• Was involved in, Integration Testing, and User Acceptance Test using the test cases given by the client before releasing the application.
• Interacted with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated the scripts to make sure they have been executed correctly and meets the scenario description.
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Wrote test cases and test scripts for the User Acceptance testing.

Environment: Mumps Cache, IDX, MS Visio, Word, Excel, PowerPoint, CMMI, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, Oracle, J2EE technology, Java, Perl.