SUMMARY:

• Over 6 years of professional experience as Business Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process
• Reengineering in Health Care Sector with prime focus on claims adjudication, provider, member, eligibility and prior authorization for Medicaid and Medicare programs. Recent projects involved up - gradation relating to HIPAA compliance ANSI X12
• Extensive experience in gathering requirements with excellent writing skills in creating business requirement documents (BRD), Functional Requirement Documentation (FRD), Non-functional Requirement Documents, and System Requirement Specification (SRS).
• Developed detailed functional specifications through JAD sessions, interviews brainstorming, reverse engineering and on-site meetings with SMEs, business users and development team.
• Comprehensive experience in different SDLC methodologies: Waterfall, Agile and RUP.
• Hands on experience with IBM Rational Software integrated tools like Requisite Pro for requirement management and analysis.
• Experience in writing Test Plan, Test Cases (manual/automated test cases), and Test Script.
• Involved in various testing like Integration testing, Regression testing, Black Box/White Box testing, User Acceptance Testing (UAT).
• Designed Activity, State and Sequence diagram using MS Visio and Rational Rose.
• Gathered good knowledge in RDBMS, Oracle, SQL, PL/SQL along with MS SQL administrator, SQL Enterprise manager, and data analysis and reporting.
• Skilled in mapping business requirements and maintaining Requirement Traceability Matrix (RTM).
• Experienced with data analysis, data mapping and dimensional modeling
• Experienced with decision support systems (data marts) using Star Schema.
• Conducted GAP analysis, Impact analysis, Interface Analysis, Root Cause Analysis and also Prototype development.
• Good knowledge on different modules with healthcare in FACETS (, enrollment, claims, providers) front-end application/GUI and back-end application/Data Model.
• Experienced with Medicare, Medicaid, Medigap and commercial insurance in HIPAA ANSI X12 4010, 5010 formats including 270, 271, 276, 277, 837(I/P/D), 835, 997, NSF formats, NCPDP formats for interfaces and images to clearinghouses/ trading partners applications.
• Familiar with different codes like ICD9, ICD10 (CM/PCS), NDC, DRG, CPT, and HCPCS codes.
• Good experience of working with healthcare claim processing in FACETS Data Model.
• In-depth knowledge and experience in Medicare (Part A, B, C, D) and Medicaid systems and CMS regulations.
• Ability to learn and work quickly in a cross-functional team environment/different geographical locations teams with excellent problem-solving and interpersonal skill.

TECHNICAL SKILLS:

Methodologies: RUP, Agile, Waterfall

Project management tools: Microsoft project, Microsoft Office

UML Modeling Tools: Rational Rose, Microsoft Visio

Change Management Tools: Rational Requisite Pro, Clear Quest, Test Director

Version Control Systems: Rational Clear Case

Testing Tools: Quality Center, Win Runner, and Load Runner.

Languages: C, C++, Java, .Net, XML, UML, HTML.

Operating Systems: Windows Family, Familiar with UNIX and LINUX

Databases: Oracle, MS SQL Server 2000, MS-Access

Reporting Tools: Business Objects, Crystal Reports, Cognos.

PROFESSIONAL EXPERIENCE:

Confidential, OMAHA, NE

Business Analyst

Environment: FACETS 4.71,RUP, Mercury Quality Center, Data stage, SQL, Unified Modeling language, Microsoft Visio, MS SQL Server, Business Objects.

Responsibilities:

• Prepared Business Requirement Document (BRD) and functional requirement document (FRD) for the enhancement of existing services.
• Used AGILE methodologies to configure and develop process, standards and procedures.
• Conducted HIPAA requirements gathering sessions for the EDI transaction between providers, payers and employer groups.
• Coordinated the upgrade of Transaction sets 837(I/P), 835 and 834 to HIPAA compliance.
• Performed Gap Analysis for HIPAA up gradation and prepared solution documents and project plan.
• Involved in forward Mapping from ICD 9 to ICD 10 and backward mapping from ICD 10 to ICD 9 using GEM (General Equivalence Mapping).
• Performed Gap Analysis between ICD 9 and ICD 10.
• Conducted numerous JAD sessions with business users, developer and SMEs.
• Tested EDI transaction like 270, 271,276,277, 837, and 835.
• Designed business process models (BPM) using UML diagrams such as use case model, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams in MS Visio.
• Went through the companion guide of the organization to understand the 837 and 834 segments to identify those needs to be changed.
• Worked broadly in the FACETS modules: module, Claims Module and Provider module.
• Worked in FACETS Batch Process such as Eligibility Batch Process, Mass Plan Change Batch Process, and ID card batch process.
• Managed test file trading with external Trading Partners (Clients / Payers, Providers, Clearinghouses).
• Involved in the FACETS configuration, customization, benefit analysis, data model.
• Involved with Data Mapping between various source systems and staging area and data marts.
• Attended daily SCRUM meeting and guided QA and Developer regarding the defects, Technical Specification Documents and Mapping Documents
• Used SQL queries to acquire data for testing and Claim analysis.
• Dealt with Host Plan/Home Plan interfaces and tested the various SF/DF/RF messages in ITS.

Confidential, Phoenix, AZ

Business Analyst

Environment: FACETS, Mainframe RUP, Rational Rose, MS Office Tools, UML, MS Visio, Windows XP, SAS, PL\SQL, Rational Clear Quest.

Responsibilities:

• Performed requirements gathering, analysis including data analysis and design of COB program.
• Designed packages to support HIPAA requirements for claim such as CPT or HCPCS coding codes, ICD -9 coding.
• Performed analysis of ICD 9 procedural and diagnosis codes in accordance with ICD 10 CM and ICD 10 PCS conversion compliance.
• Involved in HIPAA conversion analysis, documentation of HIPAA 5010 changes to EDI 837, 834, 835, 276, 277 transactions.
• Analyzed and documented the requirements for CMS.
• Worked with QA team to develop test strategies and test scenarios for all 837 P, I, D, 835, 834, 270/271, 276/277 transactions.
• Interviewed business users asking detailed questions to write business requirements documents (BRD) concerning the project.
• Conducted JAD sessions with stakeholders to analyze system needs and integrate requirement to develop a consistent navigation structure.
• Measured the success/failure/demand for new or existing features.
• Designed and developed Use Cases, UML Activity Diagrams, and Sequence Diagrams.
• Verified the functionality coverage by implementing RTM (Requirement Traceability Matrix) and Business Requirement Specification Document.
• Assisted informational needs in mapping of Test Cases also coordinated with QA and User acceptance team.
• Involved in running the Claim batch process in FACETS.
• Wrote SQL scripts for data retrieval and reporting support using SAS.
• Worked on SDLC and implemented RUP (Rational Unified Process with Requisite Pro and Rational Rose) to reduce product development time.
• Organized weekly Project Status and Task Review meetings

Confidential, Irving, TX

Business Analyst

Environment: Trizetto FACETS, Rational Requisite Pro, Clear Case, MS Visio, MS Project, SQL, Windows 2000, MSOffice.

Responsibilities:

• Gathered and documented business requirements from SMEs, user groups and vendors via workshops, interviews and surveys.
• Prepared a comprehensive Functional Requirements Document and Supplementary Specification Document (nonfunctional) using the AGILE methodology.
• Worked in Healthcare Claims Administration - Healthcare Claims Processing (837/835) includes facility claims and professional claims.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication).
• Facilitated meeting sessions with committee of SMEs from various business areas including Benefits Administration, Health Claims Group, HIPAA Administration, Health Policy and Program Evaluation Team and Data Management Group.
• Created Functional specifications for the 834 enrolment files with their changed benefits in the Medicare program.
• Gathered and documented requirements for Pharmacy benefit managers (PBMs) for health insurance carriers.
• Generated PDE and worked on reconciliation, compliance and audit for CMS.
• Performed Integration testing, Regression testing, and Black Box/White Box testing.
• Submitted change requests in Clear quest.
• Involved in Configuration Management, Requirement management and analysis.

Confidential, Chicago, IL

Business Analyst

Environment: SDLC, Agile, C, C++, MS Visio, MS Project, MS Office Suite (Word, Excel, Access, Power Point, Outlook).

Responsibilities:

• Created Business requirement documents (BRD), Functional requirement document (FRD), wrote the use cases for the requirements.
• Strategized implementation of Agile with Scrums throughout SDLC.
• Attended demo sessions to understand existing system functionalities.
• Arranged interviews with all the stakeholders to review and understand the gathered business requirements.
• Coordinated with system architects and developers to convert business requirements into system requirements.
• Conducted meetings to document Change Requests for new requirements.
• Analyzed business requirements and segregated them into Use Cases. Created Use case diagrams and documented Use case specifications.
• Maintained various versions of the documents generated during the project using Rational Clear Case.
• Was responsible for creating and updating project schedule and managing resources and timeline using MS Project.
• Prepared the project status reports and represented the BA team in the PMO meetings.
• Participated in UAT along with the development & testing teams.
• Followed prototype model of SDLC in developing software.

Confidential

Business Analyst

Environment: Window 98, UML 2.0, MS Visio 2000, MS Project 2000, MS Office 2000 (Excel, Word, Access PowerPoint), SQL Server 6.5.

Responsibilities:

• Gathered requirements and specifications, project planning and identifying the resources and implementation of the project
• Conducted Market Segmentation to identify and attract the target consumers, potential and non-potential consumer.
• Implemented Waterfall methodology throughout the SDLC.
• Conducted JAD sessions, surveys, and interviews to identify business rules and end-user's requirements.
• Utilized Rational Unified Process to create use cases, activity, class diagrams and workflow process diagrams.
• Attended daily SCRUM meeting and guided QA and IT Developer regarding the defects.
• Reviewed existing system, performed the analysis of the previous systems, and generated a detailed requirements document describing new system architecture through use cases diagrams, activity diagrams using MS Visio.
• Determine the customer relationship management process and allocate the necessary resources for smooth functioning of the procedure.
• Designed state diagram, flow diagrams, sequence diagrams and business process models.
• Conducted requirement workshops among all project stakeholders to verify and validate the business requirements in UI designs.
• Supported the Program Manager in balancing project goals and business needs.
• Worked in management information system department on reporting compliance, security and privacy issues.