SUMMARY

• Expert analytical skills in gathering business requirements through analyzing the needs of Business and Stakeholders and converting them into functional/technical requirements.
• Thorough knowledge of industry standard Software Development Life Cycle (SDLC) methodologies, such as Waterfall, Agile, RAD and RUP.
• Participated in complete life cycle of software development including design, development, testing, technical documentation, and production support.
• Skilled at performing Gap analysis, Impact and Feasibility analysis, with good knowledge of process workflow tools and techniques.
• Adept in gathering requirements through Joint Application Development (JAD) sessions and Surveys. Interviewed subject matter experts (SMEs) with superior organizational and presentation skills.
• Extensive experience in analyzing and creating Use Cases, Use Case Diagrams, Data Flow Diagrams, Business Flow Diagrams, Navigational Flow diagrams and Wireframes.
• Comprehensive Knowledge in reviewing Test Procedures, creating Test plans, defining Test cases, and executed many test cases.
• Performed User Acceptance Testing (UAT) Manually and Created relevant UAT artifacts
• Adequate knowledge of using database applications such as SQL Server and MS Access.
• Analyzing issues that might arise pertaining to Enrollment, Disenrollment, Premiums, LEP, LIS, COB’s, RX and more complex issues, using Market Prominence, Excel, and other computer programs.
• In - depth knowledge of ACA (Affordable Care Act), CMS guidelines, EDI including 820, 834, 835, 837, 999, 1095, ICD 9 & 10 codes, and HIPAA guidelines.
• Possess exceptional organizational skills, with the ability to multi-task, learning new technologies and quickly adapting to work environment.
• Recent assignments include working with Payer Organizations on up-gradation projects (EDI ASC X12 4010 to 5010; ICD-9 to ICD-10; FACETS).

TECHNICAL SKILLS:

Methodologies: RUP, RAD, Waterfall, Agile, Joint Application Development (JAD), Unified Modeling Language (UML), SWOT.

Testing Tools: JAMA, ALM, Rational Enterprise Suite, Load Runner, QTP, HPQC

Change Management Tools: JAMA, ALM, Rational Clear Quest, Test Director

Business Modeling Tools: Rational Rose, Requisite Pro, Microsoft Visio, Lucid Chart

Version Control Systems: Rational Clear Case

Programming Languages: SQL

MS Office Suite: MS Word, MS Excel, MS PowerPoint, MS Access, MS Outlook

PROFESSIONAL EXPERIENCE:

Confidential, Tempe, AZ

Business Analyst

Responsibilities:

• Interacted with the Business users, SME’s, Developers, PMs and QA teams to better understand the business processes and application knowledge.
• Worked on FACETS Data tables and created audit reports using queries.
• Manually loaded data in FACETS and have good knowledge on FACETS business rules.
• GAP analysis of 4010 and 5010, to facilitate the transition to 5010 in accordance with HIPAA standards.
• Understood the ‘AS-IS’ and ‘TO-BE’ business (current and future flow) and developed BRD and FRD.
• Identified EDI inbound and outbound transactions and mapped the provided data.
• Did the forward and backward data mapping between the fields in mainframe and FACETS.
• Worked on Payer Provider credentialing, contracting, billing and claims issues.
• Documented and gathered Functional specifications for 837 (claims),834(member Eligibility), 278 (Authorization) and 270/271 (Eligibility and Benefit Response).
• Understood Functional/Technical (Data Model) flow of 4010 HIPAA Transactions and identified the new segments/element changes required, with minimum impact on the system.
• Conducted brainstorming sessions to analyze provider contracts, medical policies and medical management rules for transition to ICD-10.
• Collected the information of ongoing ICD-10 upgrade process and performed the Impact analysis to identify problems, risks, concerns associated with the ICD-10 implementation.
• Developed Traceability Matrix to ensure full coverage of requirements.
• Used MS SharePoint to manage the repository of requirement for traceability and version control.
• Performed UAT testing coordinating with BA, Developers, and SMEs and actively involved in Production phase testing.
• Documented Maintained all the Project Changes Request (PCR) and Work Product Review (WPR) documents and updated them accordingly.
• Created Use Case diagrams by analyzing the business process, followed by Activity diagrams using MS-Visio and participated in production of HIPAA 5010 EDI Test data.
• Created test plans, test cases and participated with QA team in testing the functionality of the application by inserting varying data on different test runs.
• Involved in testing of Member Enrollment, Eligibility Enquiry, Eligibility Response, Claim Status Enquiry, Claim Status Response and conversion of Financial Claims.
• Performed User Acceptance Testing (UAT) Manually.
• Worked on billing operations for specialty care, hospital care, filing claims, posting charges and payments, collections, transcription and payer contracting/credentialing.
• Tracking the UAT defects and retesting UAT defects in Test Environment before new code gets moved to UAT environment.

Environment: Facets 5.1, Facets interfaces (IFOX), Facets extensions, UML, HTML, XML, Facets, Toad, SQL, Subversion, Requisite Pro, Quality Center 9.5, HIPAA ASC X12 4010/5010, ICD-9 & 10, MS Visio, Tracer, SharePoint.

Confidential

Sr. Business System analyst

Responsibilities:

• Conducted multiple JAD sessions with various organizations such as DHS, HHC, DCCA to elicit system requirements using stakeholder analysis, RACI chart, user stories and prototypes.
• Created BRD, FSD and SDD for the implementation of functional areas across IF, Notifications and Languages.
• Policy review to implement the blueprint requirements for Medicaid/MMIS, CHIP and Tax Credits benefits per CMS guidelines.
• Responsible to maintain the defect log that traces back to the test cases and also to the requirements, involving Agile and Scrum methodology.
• Interacted with the SME’s to gather information about the healthcare enrollment, eligibility and health care claims processing and created Use cases/FRS traced to use cases.
• Worked extensively on Gap analysis, Root Cause Analysis and Impact analysis of requirements to meet the gap and redesigning the user interface.
• Worked on many Change Requests, Parking Lot items, Action Items, Process Flow Diagrams (UML), and Use Cases.
• Primary liaison between the development team and the business owner to understand and implement the amendment and modification required through change request or work request.
• Responsible for creating Dashboards, Memos, RTM, Defect reports for CMS and other organizations.
• Creating relevant UAT artifacts including UAT test plans, UAT test scenarios and UAT test cases to be executed during UAT.
• Responsible for data analytics to support the marketing and outreach planning.
• Analysis of customer request/complains/suggestion to propose business opportunity and sustainability to the executives by creating SOWs across various functional areas.
• Created wireframes for the website design/Web Layout with the GUI design team encompassing the industrial standard of UX designs, to manage the existing and new applicants.
• Utilized SIEBEL CRM for management of Service request, verification, change processes and transaction code/status verification.
• Hands on experience for traceability matrix- to validate the SIEBEL CRM functionality per the functional and non-functional requirements.
• Member of CCB to propose a CR(Change request) to enhance the SIEBEL CRM functionality or to produce a change in the given functionality. The CRs to be managed by ALM and JAMA.
• Set-up, co-ordinate & conduct system & UAT testing with Business Users and end-field users after the applications were all set.
• Enrolling members in insurance plans, using MHC, Market Prominence, Excel, and other applications.
• EDI transactions: Participated in triage call for 834, 820 and 999 transactions, per HIPAA compliance.
• QA: Implemented test plans, test scripts for fixes and releases with EBF and HF by practicing AGILE - SCRUM Master methodology using User stories for Epics.

Environment: SIEBEL CRM 8.2.2.2, ALM, JAMA, Agile, UML, SQL, MS Office, MS-Visio, Rational Requisite Pro, Lucid chart.

Confidential, Cranbury, NJ

BUSINESS ANALYST

Responsibilities:

• Participated in ICD 9 and LOINC codes mapping sessions as well as status meetings and provided comments and suggestions on challenges before it is implemented on SIEBEL platform.
• Processed EDI/X12 (HIPAA and HL7) test files and verified system is able to validate certified and non-certified trading partners.
• Involved in configuration of FACETS Subscriber/Member application.
• Created an enterprise workflow application with COTS GUI, based on CRUD rules for Customer data that would allow for future integration of data infrastructure across various business areas into a single User Interface (SIEBEL) for constant data monitoring and data validation.
• Involved in testing different interfaces and web application forFACETS.
• Utilized Agile Methodology to configure and develop process, standards, and procedures to create the documents.
• Developed business process, logics and specification documents as well as high-level project plan and translated business requirements into data and process models following BABOK and PMBOK protocols.
• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system (Amysis) to FACETS (Client Server based system).
• Developed process decomposition diagrams, data models, data flowcharts, entity relationship diagrams, screen mockups and state diagrams.
• Set up work flowcharts, and worked in close conjunction with Business Process Modeling tools for users for the procedures in claims with the help of SMEs using BPMN.
• Worked as lead claims representative with EDI team to analyze returned Medicaid encounter messages to resolve data integrity issues.
• Developed scripts, scenarios and performed comprehensive testing - UAT, Alpha and Beta testing of applications.
• Get the Facets Claim IDs from X12 in HTM, HP environment and verify them in the Claim Adjudication system.
• Worked in depth with EDI team to crosswalk data sets to 4010 837P and 837I format.
• Performed relational database design and modeling and conducted numerous SQL queries.
• Participated in meetings to discuss test plans, resource utilization and defect tracking.
• Used Rational Clear Quest for defect tracking and prioritizing defects and for enhancements after base lining the requirements.

Environment: SIEBEL, Facets 4.81, Agile-Scrum, UML, SQL, MS Office, MS-Visio, Rational Requisite Pro.

Confidential, Louisville, KY

BUSINESS SYSTEMS ANALYST

Responsibilities:

• Participated in creation of Business Process Workflow Diagrams with Stakeholders.
• Conducted meetings with business users and SMEs to identify and gather various functional and non-functional requirements.
• Conducted GAP analysis on the different reports being presented to clients to accommodate their requirements.
• Adopted Rational Unified Process (RUP) methodology with emphasis on its six best practices for iterative and incremental development.
• Created artifacts such as Use Cases, Activity Diagrams, and Sequence Diagrams using MS Visio.
• Participated in team meetings to resolve issues & to improve overall implementation process.
• Knowledge of HIPAA 4010A rules to store the transactions and monitored all the HIPAA transactions through the gateway.
• Played a key role in planning, testing, and implementing system enhancement requests.
• Planned all the RUP iterations and documented the artifacts throughout various phases.
• Conducted JAD sessions during the various stages of upgrading the matching system and discuss the current system preferences.
• Helped identifying reports for decision support system and interacted with database designers and architects for gathering the requirements for reporting.
• Worked closely with the Lead Business Analyst to monitor progress, and the deliverables for the project.
• Reviewed System Test Plans, wrote test scripts and worked with business folks to validate and execute the test scripts.
• Involved throughout the business solutionDevelopment Life Cycle(SDLC).
• Conducted meetings with business users andSMEsto identify and gather variousfunctionalandnon-functionalrequirements.
• Constructed the Business Requirement Document and the Systems Requirement Document forProfessional, Institutional andDentalClaims, transactions and Health Care Claims Acknowledgment.
• Conducted Gap analysis to understand the business model and additional functionalities to be incorporated into the new application.
• Created artifacts such asUse Cases, Activity Diagrams, and Sequence Diagramsusing MS Visio.
• Developed Requirements Tractability Matrix (RTM) using MS excel to trace each software design requirement to test case.
• Understand the various stages of aclaim life cycleand utilize the knowledge in meeting client goals.
• Created dashboard and weekly report on Cognos.
• Ensure timely approval of data loads and timely escalation of batch data issues.
• Identify all possible automation opportunities on the project and get the reports automated

Environment: UML, Facets 4.67, MS Visio, MS Excel, SharePoint.