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
• Extensive experience in gathering requirements with excellent writing skills in creatingbusiness requirement documents, Functional Requirement Documentation, Non-functional Requirement Documentsand System Requirement Specification.
• Conducted various JAD sessions, interviews, reverse engineering and on-site meetingswith SMEs, business users and development team.
• Comprehensive experience in different SDLC methodologies: Waterfall, Agile and Rational Unified Process.
• 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.
• Designed Activity, State and Sequence diagram using MS Visio and Rational Rose.
• Gathered good knowledge in RDBMS, Oracle, SQL, PL/SQL.
• Experienced with reporting, data analysis,data mapping and dimensional modeling.
• Involved in data migration and data configurations.
• Skilled in mapping business requirements and maintaining Requirement Traceability Matrix.
• Experienced with decision support systems (data marts) using Star Schema.
• Conducted GAP analysis, Impact analysis, Interface Analysis, Root Cause Analysis and also Prototype development.
• In-depth knowledge on different modules with healthcare in FACETS (, enrollment, claims, providers) GUI and Data Model.
• Experienced with in HIPAA ANSI X12 4010, 5010 formats including 835, 997, NSF formats, NCPDP formats.
• Tested various EDI transactionlike 270, 271,276,277,278,834,820,837,835.
• Familiar with different codes like ICD-9, ICD-10 (CM/PCS), NDC, DRG, CPT, and HCPCS codes.
• Worked with vendors to upgrade their Applications and different GROUPERS to a version compatible with ICD-10.
• Broad knowledge and experience inHMO, PPO, Medicare (Part A, B, C, D) and Medicaid systems and also CMS regulations.
• Strong experience in Claims Processing using MMISSystem.
• Good knowledge on different modules with healthcare in FACETS (, enrollment, claims, providers).
• Involved in the FACETS configuration, benefit analysis and Claims Processing.
• Have in-depth knowledge on FINEOS - Claim Management Software for Health/Life Insurance.
• Performed forward and backward data mapping between the fields in legacy system and new system.
• 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: Agile, Waterfall,RUP

Project management tools: Microsoft Project, Microsoft Office, Lotus Notes, Microsoft

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

Version Control Systems: Rational Clear Case

Testing Tools: Test Link, TRAC, Quality Center, Win Runner

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

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

UML Modeling Tools: Rational Rose, Microsoft Visio

Reporting Tools: Business Objects, Crystal Reports, Cognos.

PROFESSIONAL EXPERIENCE:

Confidential, Grand Rapids,MI

Business Analyst

Environment: FACETS 4.71, SQL, Unified Modeling language, MS SQL Server, Business Objects, Microsoft Project, Word, Visio, Excel, Power Point, Microsoft Share point, Microsoft Outlook, Lotus Note.

Responsibilities:

• Involved in requirements gathering and project planning with program manager.
• Conducted numerous JAD sessions with business users, developer and SMEs.
• Involved in FACETS Configuration planning for ICD-10 with SMEs, Trizetto Team and Third party vendor.
• Analysis of inbound and outbound interfaces and extensions to FACETSclaim processing system.
• Prepared ICD-10 Technical Scope Document using inventory as a basis.
• Identified and documented requirements for the ICD-10 Enhancement.
• Performed Gap Analysis and Impact Analysisfor conversion of ICD-10.
• Heavily involved in ICD-10 data migration.
• Involved in forward Mapping from ICD-9 to ICD-10 and backward mapping from ICD-10 to ICD-9 also involved in Custom Mapping.
• Identified, developed and implemented project plans to support and drive ICD-10 key project activities.
• Extensively used SQL statements for Data Validation and Data Integrity.
• Worked with the ICD-10 technical lead to develop and validate a complete inventory of all technical remediationrequired.
• Worked with program manager and Stakeholders to prioritize the remediation inventory to coincide with the Four planned business work streams (Foundations, Compliance, Financial Neutrality, and Usage).
• Worked with developers to complete Priority Health Code Base Analysis.
• Provided daily status to the project and program managers as required.
• Generated Weekly Status Reports to the Program managers.
• Proactively notified the project and program managers of any issues that could impact the scope,quality,cost or schedule for ICD-10 project.
• Extensively involved to plan,implement and test all Third Party Applications that have an impact on Priority Health's ICD-10 readiness.
• Worked with business people to complete sufficient number of recoded medical policies to reflect the ICD-10 based benefits/coverage.
• Collaborated with QA Lead and business SMEs to develop and review test scenarios,test casesas required.
• Ability to manage requirements and excellent and verbal communication skills.

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 and functional requirement document for the enhancement of existing services.
• Performed Gap Analysis for HIPAA up gradation and prepared solution documents and project plan.
• Initiated with a comparison report of migration of HIPAA .
• Conducted HIPAA requirements gathering sessions for the EDI transaction between providers, payers and employer groups.
• Coordinated the upgrade of Transaction setsEDI 837(I/P), 835 and834 to HIPAA compliance.
• Involved in testing all the loops, segments and elements within each hierarchal loops for EDI 837i and 837p.
• Worked on solving the errors of EDI 834 load to FACETS.
• Analyzed and documented the requirements for MMIS and CMS.
• Involved in forward Mapping from and backward mapping
• 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.
• Managed test file trading with external Trading Partners (Clients / Payers, Providers, Clearinghouses).
• Worked broadly in the FACETS modules: module, Claims Module and Provider module.
• Worked on developing the business requirements and use cases for FACETS Batch processing, automating the billing entity and commission process.
• Involved in the FACETS configuration, customization, benefit analysis,data model.
• Worked on FACETS extension mapping attributes.
• Performed Gap Analysis between ICD-9 and ICD-10.
• Coordinated with SMEs andICD-10 vendor to assist in the validation of the ICD-9 to ICD-10 code mapping activities.
• Assisted the development and validation of ICD-10 documentations (code mapping, data migration, data validation, use cases).
• 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, Bloomington, IL

Business Analyst

Environment: Microsoft Share point, Microsoft Outlook Microsoft Office (Excel, Word, PPT), Test Link, Lotus Notes, Shovel, TRAC, MS SQL Server.

Responsibilities:

• Extensively involved in collecting, writing and reviewing requirements, business rules, business processes with SMEs, Business Users and Business Leads.
• Participated in the identification, understanding and documentation of business requirements including the application/LHCS capable of supporting those requirements.
• Did Gap Analysis and Impact Analysis between the existing system (HICS) and new system (LHCS).
• Completed forward and backward data mapping between the fields in legacy systems and the new system.
• Attended technical sessions to facilitate any business discussion for the integration of various legacy systems with the new system.
• Created Use Cases and Business Scenarios, Business Process Flow using MS Visio.
• Conducted JAD sessions, surveys, project related presentation and interviews to identify business rules and end-user's requirements.
• Participated in creating and reviewing Requirements Traceability Matrix (RTM), Technical Requirements Specifications (TRS), and Proposal for Resolution (PFR).
• Documented various projected related Integration documents.
• Supported the Project Planning, Project Definition, Scope Analysis and User .
• Attended various sessions conducted by Third Party Vendor (FINEOS) to review and brainstorm the Claim Software Solution and Wire Frames related to that product.
• Attended the base product provided by FINEOS team.
• Generated Weekly Status Report to Business and System Project Manager and Team Lead.
• Updated Team Lead on Status Tracker Document-includes dates, milestones, charter progress.
• Used AGILE methodologies to configure and develop process, standards and procedures.
• Attended TRIAGE session with system team, development team and provided business support as necessary.
• Worked as UAT Lead during UAT Testing.
• Created UAT Charters based on business scenario and Wire Frames and review with Business and Testing team.
• Heavily involved in writing Test Plan, Test Cases and Test Steps.
• Created and uploaded Test Charters in Test Link (Testing Tool).
• Mapped the Test Cases with requirements in Test Link.
• Used SHOVEL as a data mining tool to mine the Test data to execute the test cases.
• Created Test data Sheet and reviewed with Testing and Development team.
• Assisted SMEs, pre-determined Business User to execute UAT Testing.
• Created Tickets to log UAT Testing Defects using TRAC as a tool.
• Heavily involved in Ad hoc and Exploratory Testing with SMEs and Business Lead.
• Provided actual results of UAT Testing and reviewed System Testing actual results and reports.
• Attended daily SCRUM meeting and guided QA and Developer regarding the defects, Technical Specification Documents and Mapping Documents.

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:

• 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.
• DidGAP analysis, data analysis and design of COB load program..
• Involved in HIPAA conversion analysis, documentation of HIPAA 5010 changes to EDI 837, 834, 835, 276, 277 transactions.
• Wrote test cases for testing migration of HIPAA .
• Went through the companion guide of the organization to understand EDI 837 and 834 segments to identify those needs to be changed.
• Met with the Provider Communities and Trading Partners to ensureHIPAAtransactions pass the EDI gateway and interpret technical difficulties as required.
• 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.
• 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 Requirement Traceability Matrixand Business Requirement Specification Document.
• Assisted informational needs in mapping of Test Cases also coordinated with QA and User Acceptance Testing team.
• Designed packages to support HIPAA requirements for claim such as CPT or HCPCS coding codes, ICD -9 coding.
• 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, Irvine, TX

Business Analyst

Environment: TrizettoFACETS 4.1, 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.
• Attended demo sessions to understand existing system functionalities.
• CheckedBusinessReadiness and determined activities of flow.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Prepared comprehensive Functional Requirements Document using the AGILE methodology.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication).
• Facilitated meeting sessions with committee of SME's from various business areas including Benefits Administration, Health Claims Group, HIPAA Administration, Health Policy and Program Evaluation Team and Data Management Group.
• Worked in Healthcare Claims Processing for 837/835 includes facility claims and professional claims.
• Created Functional specifications for the 834 enrolment files with their changed benefits in the Medicare program.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to followHIPAA ANSI X12 4010formats including270 (Benefit Inquiry), 271(Benefit Information), 276 (Claim Status Request), 277 (Claim Status Response), 820 (Payment Order), 834 (Benefit Enrollment), 835 Remittance Advice and 837 Claims.
• Gathered and documented requirements for Pharmacy benefit managers (PBMs) for health insurance carriers.
• Submitted change requests in Clear quest.
• Involved in Configuration Management, Requirement management and analysis.