SUMMARY

• 7 plus years of experience in healthcare domain in ACA, EDI and Medicaid, FACETS, MITA environment
• Experience wif TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management; NetworX Pricer automated claim processing, Provider management
• Familiar wif the end to end business process in Provider Management and Member Management in MMIS
• Facilitated meeting wif SMEs’ and stakeholders to produce, design, packaging, implementation and rating SMEs’ feedback and performance
• Conducted work breakdown meeting to identify milestone, deliverables and anniversary date
• Created and shared calendar - timeline on the basis of committed dates for delivery from work effort owners
• Played as documents owner in the JAD session to answer on the questions on requirement, dependency, project current status, potential risk, assumptions, decision taken and so on
• Escalated issues to SMEs’, Sr leaderships, managers, to ensure correct message is conveyed and communication is flawless
• Completed given tasks on time and followed up wif other responsible parties and folks for smooth workstream
• Coordinated closely wif other project BA’s for updating Dashboard and present to the program level meeting and give update to the team of 50+ (including business leads, project sponsors, program director)
• Worked closely wif Program Manager, Project Manager in assigning or referring BA’s to fill in position and support them in understanding project works
• Conducted PM-BA forum on bi-weekly basis for open discussion on project works and interependencies
• Proficient understanding and demonstration knowledge of Medicaid, Medicare, EDI, ICD - 10, HIPAA 5010
• Worked alongside the Moveable Online Project Management team for defined projects, ensuring dat project deliverables meet business requirements and specifications.
• Assisted Project Manager in the development of business cases, RFI's and RFP's.
• Built and maintained effective relationships wif business and technology partners, subject matter experts to obtain consensus and support for required changes or enhancements.
• Translate customer business needs into requirements to support their online strategy.
• Provided analytical solution to the customers for Facets Production Issues.
• Worked on migration project from legacy to Cloud system - acted as liaison between business and IT to ensure all application and tool migration needs are met
• Provided operational support between the customer and internal team during the migration process; managing RAID and regular update to the stakeholder wif the work status
• Possess leadership in the projects at the both client and implementation partner stands point - present before the Sr. leadership on project outcome, dashboard updates; organizing, scheduling and attending PM-BA forum to discuss on the ongoing projects, interdependencies, learning scope and to do’s; preparing webinar (Inhouse) to arrange group learning wif knowledge sharing platform.
• Schedule and moderate the bi-weekly conference calls for the consultants wif the implementation partner Sr. Leadership to report of project status; working hours, new resource requirement opportunity; follow up wif new resources on project assignment from the Program Manager/Program Director’s office
• Competent in creating workflows, BusinessProcess Modeling (BPM), process improvements and facilitating process engagements; document business processes using visio and company in-house tools; walk through the BPM in the meeting or conference calls to ensure everyone on the same page and do needful update from the feedback
• Initiated to archiving so far created business processes on worksite for interdependency project work and new resources education program
• Processes and understanding Six Sigma methods for maximum quality improvement
• Performeddata analysis, and data and software conversions, and led multiple system implementations.
• Worked on Data migration, Facets version upgrades, Reports Implementation, letters, Inbound/outbound Interfaces and Facets Extensions. Implemented EDI transactions 835, 270/271, 276/277 and 834.
• Experience wif EDI transactions such as EDI 834 (Benefit Enrollment and Maintenance), 277/275(Health Care Claim Request for Additional Information and Response), 276/277 (Health Care Claim Status Request and Response), 835 (Health Care Claim Payment/Advice), 837P (Health Care Claim: Professional), ICD9, CPT and NDC Codes.
• Excellent knowledge of Medicare (Part A, B, C and D) and Medicaid Health Insurance Policies and reimbursement forms.
• Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicare, and implementation of HIPAA key EDI (ANSI X12) transactions.
• Dealt wif the complexity of migrating from the ICD-9 set of diagnostic codes to ICD-10.
• Experienced in complete AGILE, RUP, SDLC, Client /server architecture providing a well-balanced understanding of business relationships, business requirements, worked for financial and technical solutions and help the team at all levels until final product release.
• Experienced in writing and preparing business requirements documents (BRDs), system requirements specifications (SRS), system design specification (SDS), functional specifications, defining project plan and change request.
• Extensive experience in Requirement analysis, Business Modeling, defining business processes, sequence diagram, activity diagram, and Use Case using UML methodology.
• Strong HIPAA EDI 4010 and 5010 wif ICD-9 and ICD-10, analysis & compliance experience from, payers, providers and exchanges perspective, wif primary focus on Coordination of benefits
• Assist the Project Manager in the development of SDLC methodology and documentation strategy and act on behalf of the Project Manager during the PMs Absence.
• Facilitated UAT wif stakeholders and business users
• Excellent analytical skills for understanding the business requirements, business rules, business process and detailed design of the application; Knowledge of SQL and experience of writing SQL commands.

TECHNICAL SKILLS

Requirement Management: RequisitePro, Doors

UML Tools: MS VisioOther Tools: Putty, TOAD, FTPZilla, Notepad++, MS OfficeTesting Tools: WorkSite, Quality Center, ClearQuest, QTP

Database: Oracle, SQL

Skills: Analytical, problem solving, leadership, organized, Communication, documentation and reporting

PROFESSIONAL EXPERIENCE

Confidential, DC

Business System Analyst/ QA Tester

Responsibilities:

• Participated in company’s largest team responsible for ACA implementation under Govt. Mandates Program including ICD 10 migration and Chapter 224 -Payment reform
• Worked on migration claim processing system to NetworX Price system as per tech modernization project
• Created cost benefit analsis document for migration from legacy system to NetworX system
• Worked alongside the Moveable Online Project Management team for defined projects, ensuring dat project deliverables meet business requirements and specifications.
• Assisted Project Manager in the development of business cases, RFI's and RFP's.
• Built and maintained effective relationships wif business and technology partners, subject matter experts to obtain consensus and support for required changes or enhancements.
• Translate customer business needs into requirements to support their online strategy.
• Facilitated meeting wif SMEs’ and stakeholders to produce, design, packaging, implementation and rating SMEs’ feedback and performance
• Worked in testing the professional, institutional claims processing and adjudication and validate data wif facets.
• Worked wif the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements wifin FACETS.
• Provided analytical solution to the customers for Facets Production Issues.
• Conducted work breakdown meeting to identify milestone, deliverables and anniversary date
• Created and shared calendar-timeline on the basis of committed dates for delivery from work effort owners
• Created functional design document for web based application (FAD - Find A Doctor) wif details of each requirement me.e. priority, source, cost/benefit (high level or narrative), possible implications and dependencies
• Wireframes or screen/webpage “mock-ups)”
• Used MS Excel Pivot Tables for data analysis and reporting for status update and presentation
• Created Use Case, Prototypes for web application how it will be used (routes through a business process dat are also useful as a basis for test cases.
• Worked on and tested Interface/API functions; Screen, Window, Webpage technical process flow - menu structuring and route from screen to screen
• Played as documents owner in the JAD session to answer on the questions on requirement, dependency, project current status, potential risk, assumptions, decision taken and so on
• Escalated issues to SMEs’, Sr leaderships, managers, to ensure correct message is conveyed and communication is flawless
• Completed given tasks on time and followed up wif other responsible parties and folks for smooth workstream
• Worked on migration project from legacy to Cloud system (to Office 365) - acted as liaison between business and IT to ensure all application and tool migration needs are met; provided operational support between the customer and internal team during the migration process; managing RAID and regular update to the stakeholder wif the work status
• Coordinated closely wif other project BA’s for updating Dashboard and present to the program level meeting and give update to the team of 50+ (including business leads, project sponsors, program director)
• Worked closely wif Program Manager, Project Manager in assigning or referring BA’s to fill in position and support them in understanding project works
• Participate in assigning projects by using the performance log and skill matrix created by the PMO resource personnel - scheduling and moderate PM-BA forum
• Initiated and lead the work group in archiving the BPM - processes company created or currently being created for WIP project for resources to share and reference
• Competent in creating workflows, BPM, process improvements and facilitating process engagements; document business processes using visco and company in-house tools; walk through the BPM in the meeting or conference calls to ensure everyone on the same page and do needful update from the feedback
• Initiated to archiving so far created business processes on worksite for interdependency project work and new resources education program
• Worked wif a cross functional and diverse team of business users and developers - onsite and offsite to enable accurate communication of requirements and ensure consensus through IM, group meeting conference calls, webinar and email using ppt deck.
• Assisted in Regression Test, System Test, and UAT testing and maintain log for the business team and update in the weekly status meeting or bi-weekly program team meeting
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the gap between AS IS and TO BE and suggest Project Manager and Senior Leadership on to do.
• Developed Data Mapping and Crosswalk documents.
• Performed Impact analysis for readiness of Go Live preparation and schedule meeting inviting key resources and dependencies.
• Prepared Business Requirement Document BRD for Multi-State Plan, Native American, MAss Banker’s body-mind program, Wellness and Fitness benefit projects
• Tested claim process using the NPI and courtesy Taxonomy number using status non-Participating and Participating and also using the assigned Taxonomy number - to ensure system waive cost share when Native American members get services through India Health Service - IHS providers
• Participated and assisted ICD 10 conversion team on adhoc basis and also as focused group on surveying
• 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 wif legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Worked in testing the professional, institutional claims processing and adjudication and validate data wif facets.
• Worked wif the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements wifin FACETS.

Environment: WorkSite, MS Visio, MS Office, HP Quality Center, Toad for Oracle, Team Track, AGILE methodology, DB2, Facets, Java, Altova MApForce, MS Excel (PIVOT), Radiant

Confidential, Danville, PA

Business System Analyst

Responsibilities:

• Perform various Operations for Different Health Plan needs wifin the Macess Application Established new Medicare groups in Facets Group Application (GRGR) and linked these Groups to its Subgroup (SGSG), Class/Plan (CSPI) and Product (PDDS).
• Develop, coordinate and support Information Technology Division on all operational requirements of FACETS claims processing system and production management.
• Worked on migration claim processing system to NetworX Price system as per tech modernization project
• Created cost benefit analsis document for migration from legacy system to NetworX system
• Involved in developing database objects using FACETS database in both SQL Server and Sybase environments.
• Worked alongside the Moveable Online Project Management team for defined projects, ensuring dat project deliverables meet business requirements and specifications.
• Assisted Project Manager in the development of business cases, RFI's and RFP's.
• Built and maintained effective relationships wif business and technology partners, subject matter experts to obtain consensus and support for required changes or enhancements.
• Translate customer business needs into requirements to support their online strategy.
• Provided operational support between the customer and internal team during the migration process; managing RAID and regular update to the stakeholder wif the work status
• Worked closely wif business and IT folks along wif SME’s to amend, create, and updating process flow charts from “AS IS” to “TO BE” system.
• Used MS Excel Pivot Tables for data analysis and reporting for status update and presentation
• Worked wif a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus.
• Updating and maintaining RAID - Risk, Assumptions, Issues and Decision log and assist Project Manager in overall project work efforts.
• Worked on migration project from legacy to Cloud system (to Office 365) - acted as liaison between business and IT to ensure all application and tool migration needs are met
• Wireframes or screen/webpage “mock-ups)”
• Created Use Case, Prototypes for web application how it will be used (routes through a business process dat are also useful as a basis for test cases.
• Worked on and tested Interface/API functions; Screen, Window, Webpage technical process flow - menu structuring and route from screen to screen
• Create process flow and walk team through on the conference call/meeting and get signed off by the product owner
• Finding and documenting GAPs between legacy system vs new system and communicate wif the business and IT
• Escalated issues to SMEs’, Sr leaderships, managers, to ensure correct message is conveyed and communication is flawless
• Created UML, BusinessProcess Modeling (BPM), to interpret business processes for project work and also to present to the senior leadership while discussing on the project
• Worked on the initiative to the cloud migration project
• 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.
• Developed Data Mapping and Crosswalk documents.
• Involved in preparing several Use Cases, BPM, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Conducted PM-BA forum on bi-weekly basis for open discussion on project works and interdependencies
• 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 in testing the professional, institutional claims processing and adjudication and validate data wif facets.
• Assisted in Regression Test, System Test, and UAT.

Environment: Microsoft SharePoint, MS Visio, MS Office, HP Quality Center, Toad for Oracle, Team Track, MMIS, CMS, AGILE methodology, DB2, Facets, Java, Altova MApForce, MS Excel, MS Power Point, Radiant CMS

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Conducted JAD sessions wif Subject Matter Experts (SME’s).
• Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
• Did Presentations making Stakeholders understand how the changes would effect different modules w.r.t. Medicare and Medicaid
• Revised HCFA-1500 and MCS-1500 forms wif stakeholders.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Documented, organized and tracked the requirements using Rational Requisite Pro.
• Worked wif Source system Subject Matter Experts (SMEs) to ensure dat the extracts are properly mapped. Used SQL for data mapping and querying.
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Integrated Requisite Pro wif Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
• Assisted in writing test case scenarios for unit testing, integration testing and compliance testing.
• Assisted wif user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
• Assist end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS.

Environment: Facets, Oracle, MS Project, MS Office suite, SQL, SQL Server, Rational Suite, Citrix, MS SharePoint.

Confidential, Milwaukee, WI

Business Analyst

Responsibilities:

• Conducted JAD sessions wif Subject Matter Experts (SME’s).
• Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
• Did Presentations making Stakeholders understand how the changes would effect different modules w.r.t. Medicare and Medicaid
• Revised HCFA-1500 and MCS-1500 forms wif stakeholders.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Documented, organized and tracked the requirements using Rational Requisite Pro.
• Worked wif Source system Subject Matter Experts (SMEs) to ensure dat the extracts are properly mapped. Used SQL for data mapping and querying.
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Integrated Requisite Pro wif Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
• Assisted in writing test case scenarios for unit testing, integration testing and compliance testing.
• Assisted wif user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
• Assist end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS.

Environment: Facets, Oracle, MS Project, MS Office suite, SQL, SQL Server, Rational Suite, Citrix, MS SharePoint.

Confidential, Denver, CO

Business Analyst/QA Tester

Responsibilities:

• Gatheird analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Performed Data mapping on the extracted data, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835 to identify key data set elements for designated record set. Interacted wif Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Involved in preparing Test Plan and Test Cases based on business requirements.
• Wrote Test Cases based on Technical Specifications, Functional Specifications and Business rules for online application system.
• Authored Test cases for HIPAA EDI Transactions 270/271, 276/277,837/835.
• Tested HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Executed Test cases manually by composing 270, 276,837 EDI files and dropped inbound and check response 271,277,835 using interleaves and outbound
• Designed and developed Use Cases and Use Case scenarios, Activity Diagrams, Sequence Diagrams, High Level and Low Level Process Flow Diagrams, OOAD using UML and Business Process Modeling.
• Responsible for creating test case scenarios, creating test data plan and writing test scripts for the UAT using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Conducted surveys, interviews, and JRP, JAR and JAD sessions and translated them into system Requirements. Suggested measures and recommendations to improve the current application performance of the system.
• Responsible for preparing Business Requirement Document (BRD), Functional Requirement Document (FRD) and then translating into functional specifications and test plans. Closely coordinated wif both business users and developers for arriving at a mutually acceptable solution.
• Performed Gap Analysis in every phase and stages to check the compatibility of the existing system infrastructure wif the new business requirements.
• Provided highly complex analytical support through the analysis and interpretation of data in support of cross-functional business operations.
• Developed budget tools and templates, and prepared and analyzed highly complex financial and budget reports for management review.

Environment: RUP, COBOL, CICS, Citrix, DB2, MS Excel, MS Word, MS Access, MS Project, MS Visio.

Confidential, New York, NY

Jr. Business Analyst

Responsibilities:

• Elicited requirements from the stakeholders using various requirement gathering techniques such as: end-user interviews, job shadowing, questionnaires, etc.
• Created “As-Is” and “To-Be” process maps and conducted a gap analysis.
• Created business requirement documents based on high level requirements, and producer manuals.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives wif each other, resolve any issues and come to an agreement quickly and ascertain dat requirements were feasible.
• Led business analysts and testers during the development and execution of test cases, verifying test results and documented defects.
• Developed test plans, test conditions, and test cases from business/functional/technical requirements.
• Developed Excel formulas for testing and verification of insurance premiums, forward/backward traceability of functional requirements to test scenarios/test cases.
• Trained testers to create test cases and manually calculated insurance premiums by using specifications and insurance rules.
• Used VISIO to draw the diagrams required in the development efforts.
• Participated in conference calls to figure out the scope and the needs of the business requirements.
• Created UI Documents as supporting documents for the Business Requirements Documents.
• Involved in Data Flow/Business Process Diagrams to illustrate the flow, input and output of data.
• Developed a Test Plan for testing the application after reviewing requirement specification document.
• Involved in Business Process Management (BPM) activities like Process Design, Process Monitoring and Process Execution
• Effectively and timely completed client project which met and exceeded client expectations
• Prepared workflow charts and diagrams to specify in detail operations to be performed by equipment and computer programs and operations to be preferred.

Environment: JIRA, MS Excel/Word/FrontPage, Agile (SCRUM), Lotus Notes, Cisco VPN client, Citrix ICA client, Microsoft SQL Server, Windows.