SUMMARY:

• Over 7 years of experience in software development in Healthcare, Health Insuranceand Pharmacy domains.
• Expertise on Data Extraction process, Business Intelligence/Report Generation, Application UI Enhancements, HIPAA EDI 5010 Implementation,ICD - 10 Implementation, and Healthcare Claims Processing.
• Functional experience with emphasis on Business Analysis, Business Process Modeling (BPM), Use Case modeling using UML, Data Modeling, Data Mapping, Data Warehousing, Business Intelligence/Reporting, Project Management, Change Management, and QA testing.
• Experienced in requirement gathering, data collection, analysis and evaluation in information systems issues, analytical problem solving and decision making, communication and inter-personal skills with ability to interact with individuals at all levels.
• Experienced in various SDLC methodologies such as RUP, Agile-Scrum, Waterfall covering multiple phases from initiation through implementation.
• Transformed business requirements into functional specifications, focusing on workflow analysis, GAP analysis, system design, business process re-engineering, and user interface (UI) design.
• Adept at creating and transforming business requirements into functional requirements and designing business models using UML diagrams - i.e. Use Case, Sequence, Activity, and Context diagrams using the toolMS Visio.
• Implemented Unified Modeling Language (UML) methodologies to design Use Case Diagrams, Data Flow Diagrams, Activity Diagrams, Sequence Diagram and ER diagrams
• Conducted various JAD sessions with business users, the developmentand QA resources in order to refine the requirements, discuss issues or impediments, and clarify any ambiguities to the solution.
• Designed the relational database by documenting Entity Relationship Diagrams (ERD), Activity Diagrams and Sequence Diagrams in the Functional Specifications document (FSD).
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
• Proficient in writing SQL queries, and Database (MS SQL Server, My SQL, Oracle) technologies.
• Assisted the technical team in translating application functionality into application architecture and the production of a System Functionality document.
• Well versed with HL-7, HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions.
• Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both Inpatients, outpatients,Reimbursement Methodology.
• Managed and developed EDI specifications, GAP Analysis and applications structures for data feeds and mappings for integration between various systems to follow ICD 10 Code Set, ANSI X12 formats including 270 Eligibility Benefit Inquiry, 271 Eligibility Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice, 837 Claims and Encounter, and 997 File Transmission Acknowledgement, to meet HIPAA requirements
• Experienced inICD 9, ICD 10, and HIPAA 4010/5010 EDI transactions.
• Experienced with healthcare systems, HIPAA compliance applications and electronic exchange guidelines including 850,856,810 and210 EDI documents.

TECHNICAL SKILLS:

Tools: MS Office Suite (Word, Excel, Power Point, Project, Access), Outlook, MS SharePoint, ADR, HIPAA Suite, Trizetto Facets, IBM Lotus Notes, Web Server Internet Information Server (IIS), HP Service Desk

Analysis Tools / Techniques: RUP, UML, Object Oriented Analysis, Rational Rose, ERwin, Visio, Rational Requisite Pro, Data Analysis, Data Modeling, Logical and Physical Database Design, ETL Analysis, Dashboard Design

SDLC: RUP, Agile, Scrum, Waterfall

UI Design/ Mockup: SnagIt, iRise, Photoshop

Testing Tools: HP Quality Center, HP Quick Test Professional (QTP)

Reporting Tools: Cognos, Crystal Reports, Business Objects

Database: SQL Server 2000, Oracle 8i/9i/11i, Teradata, MS-Access

OperatingSystems: Windows XP, Advanced Server, Windows 2x, Windows NT, UNIX

Languages: VB 6.0, ASP, XML, XSLT, HTML, DHTML, C++, Java, VB Script, JavaScript

Programming Tools: Visual Interdev 6.0, Visual SourceSafe, UML, Rational Purify, Rational ClearCase

PROFESSIONAL EXPERIENCE:

Confidential, Downey, CA

Business Systems Analyst

Responsibilities:

• Active participation in client meetings to elicit the business requirements from the stakeholders and understand the specifications of the application to be enhanced or the reports to be remediated.
• DevelopedBusiness Requirements Documents (BRD) based on the requirements elicited from the stakeholders indicating project scope, objectives, assumptions, dependencies and risks; and translating further these business requirements into specific user requirements.
• Defined clearly the scope of the project, set forth the objectives, and frame up the scope to prevent any scope creep.
• Coordinated with the stakeholders including theBusiness Sponsor, Client members, SME (Subject Matter Expert), Project Manager, Developers, DBAs, QAresources, and Pharmacists, for any clarification on the requirement and to ensure consistency in requirement.
• Managed all the issues, feedback and comments based on the shareholders’ review of the BRD, FRD and LSDD. Incorporated changes accordingly based on the stakeholders’ feedback.
• Authored various types of artifacts such as Business Requirements (BRD), Functional Requirements (FRD), Logical Solutions Design (LSDD), GAP Analysis, Business Process Diagrams, Release Notes, and Project Charter.
• Experienced in developing the Logical Solutions Design Document (LSDD) detailing the technical aspects of the application such as the system interface design, system architecture, data flow, business process flow, context diagram, and database structure.
• Illustrated the existing process (AS-IS) versus the new process (TO-BE) via GAP Analysis which would provide solution to the business need using the diagramming tool MS Visio.
• Experienced in writing numerous SQL Queries and performing ADHOC analysis.
• Created UML Diagrams such as Use Case, Activity, Sequence, Swim Lanes, Context, Data Flow, System Interfaces,Entity Relationship diagram (ERD) using the MS Visio.
• ConductedJAD (Joint Application Development) sessions to clarify any ambiguities in the requirements/ resolve issues.
• ConductedRequirement Validation via comprehensive walkthrough of the business requirements and functional specifications with the stakeholders.
• Collaborated with the Database Architect on the Database Model, Data Dictionary, Data Models, Design, Schema as well as in developing the Entity Relationship Diagram (ERD) in order to identify the different tables within the database to derive data for an application.
• Thorough analysis the Data Mapping files to understand the mapping out of data from the legacy system to the new system.
• Created Data Mapping in collaboration with the DBAs and Data Programmersin identifying the source tables and columns, and understanding the logic in extracting data from the new pharmacy system to create new reports.
• Collaborated with development team to understand the current system, limitations and scope to better capture the need for new enhancements / changes / bug-fixes.
• Reviewed test cases,and test scenarios with Quality Assurance to ensure alignment with the business requirements and functional specifications.
• Participated in functional and regression testing and reported the identified bugs to defect tracking tool.
• Familiarity with the ETL process to understand data in terms of extraction, transmission, processing, refining, and the eventual uploading to the main database and distributed to other systems.
• Worked with the Training team in putting up a User’s manual as a guideline for users on how the new functionalities work.

Environment: Java, Asp.Net, Cognos, Teradata, Oracle 11,SQL Server, Informatica, EPIC-Health Connect, Clarity, MS Visio, MS Office (Word, Excel, Powerpoint), MS Project, Windows NT, Lotus Notes, HP Quality Center, RUP, Agile-Scrum, Waterfall.

Confidential, Salt Lake City, UT

Business Analyst

Responsibilities:

• Identified & documented impacts to Claim processing operations for5010 implementation of transaction codes 834, 837, 835, 270/271, and 276/277.
• Prepared the Business Requirement Documents (BRD) and Functional Requirement documents (FRD) for the enhancement of the existing services.
• Worked on HIPAA compliance failures in inbound and outbound Medicare claim adjudication transactions.
• Gathered requirements from the business stakeholders via aJAD session.
• Claims development and maintenance in MMIS mainframe environment, system integration, and regression testing.
• Analysis and design of existing transaction sets to ensure HIPAA compliance.
• GAP Analysis between ICD 9 and ICD 10 based on GEMS (General Equivalence Mapping).
• Assisted Developers in Data Modeling using Entity Relationship Diagrams (ERD).
• Prepared custom reports and performed SQL query, data analysis and verification on Oracle.
• Involved in mentoring specific projects in application of the new SDLC based on the RUP, especially from the project management, requirements and architecture perspectives.
• Defined theproject scope to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Created workflow diagrams, UML diagrams, Process Models, Activity diagrams, Use Cases, etc.
• Documented business rules, created activity flow diagrams, and validated entity relationship diagrams.
• GAP Analysis for HIPAA P and 835 transactions and HIPAA P and 835transactions.
• Evaluated HIPAA Suite Claim Responder tool to be used for 276/277 transactions as interim solution for a decommissioning claims platform.
• Reviewed business UAT test scenarios with end users and coordinated with IT for executing those.

Environment: Trizetto FACETS, HIPAA Suite, SQL Server, IVR, XML, MS Access, MS Visio, MS Office, MS Project, Eclipse.

Confidential, Cypress, CA

Business Systems Analyst

Responsibilities:

• Acted as a key liaison between the business group and the development group.
• Creation of Business Requirement Documents (BRD) and Functional Specifications Documents (FRD) giving the in-depth functional details, ETL logic, business rules in detail.
• Complete ownership of Medical Claims, Revenue subject areas.
• GAP Analysis of data requirements between source and target system.
• Requirements were captured using Rational Requisite Pro.
• Adept at conducting User Interviews and Joint Application Development (JAD) sessions for eliciting Business Requirements, System Specifications and Functional Requirements.
• Identification of business rules for data transformation.
• Design of extract file format, column fields to be included, primary keys, grouping keys, indexes.
• Creation of business rules for grouping logic for extract files.
• Utilized a variety of reporting tools such as Crystal Reports and Oracle for querying underlying database tables and resolve data issues.
• System testing, analysis support in defect fixing, and regression testing. Testing done in SIT and Pre-Prod environments.
• Educating business users about the data arrangement, new report structures in target system.

Environment: RUP, MS Word, Excel, PowerPoint, Project, Visio, Sharepoint, ADR, Oracle, SQL, IBM Datastage, ETL, EDI, Requisite Pro, Mercury TestDirector, Mercury Quality Center, IVR

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Analysis of Revenue, Membership, Claims data housed in EPIC Clarity database on Teradata.
• Responsible for Medicaid Claims Resolution/Reimbursement for state health plans using MMIS.
• Updated MMIS(Medicaid Management Information System) with third party insurance information through an automated process.
• GAP Analysis of metric calculation requirements between national and various regional teams including standardization of those rules and metric calculations.
• Identified, analyzed, and documented current (AS-IS)business process model and desired (TO-BE)business process model.
• Developed Use Cases and Activity Process Flow diagrams using MS Visio for the FACETS Membership Enrollment process.
• Worked with X12 standard SME for 834 and 837 transaction sets requirements.
• Acted as a liaison between business staff and technical staff to articulate and communicate their needs, issues and concerns.
• Prepared Data Flow Models for code sets validating in FACETS and Claim Process Engine.
• Documented, reviewed, and verified testing procedures for compliance to interface Quality Assurance and Development standards and policies and other required standards.
• Assisted with User Testing of systems (UAT) and ensuring that appropriate documentation was in place.
• Identified and documented issues, risks, gaps and their impact to the project life cycle.
• Supporting ETL development team in understanding the requirements and building the ETL logic, datamarts, extract feeds, report creation.

Environment: UML, SAP, Microsoft Office (Project, Publisher, Excel, Word, PowerPoint and Visio), TM Facets, Issue Tracker, Hyperion BI Applications, Lotus Notes 6.5, SDLC, Oracle 10g and VPN Client

Confidential, Basking Ridge, NJ

Business Analyst

Responsibilities:

• Performed analysis on existing systems, recommended enhancements, and implemented strategies to streamline current processes using UML.
• Utilized Business Process Modeling to streamline the existing processes, channels through which customers contact UHC (like phone, web, email, thru doctors, pharmacies, etc.). Similar process modeling was done for claim processing as well, thereby, eliminating the roadblocks in claim mapping, member identification, claims adjudication, removing duplicate claims.
• Coordinated with the lead Business Analysts to drive the requirements and change requests in the CRM customization.
• Created the Use Case diagrams, Sequence diagrams using Rational Rose based on RUP, UML methods.
• Prepared BRDs (Business Requirement Documents) supporting documents containing the essential business elements, and detailed of business data requirements. Also prepared detailed Functional Specification documents (FSD).
• Assisted the Project Manager in setting realistic project expectations and in evaluating the impact of changes on the project plans accordingly and conducted project related presentations.
• Assisted with User Acceptance Testing (UAT), developing and maintaining quality procedures.
• Conducted Testing in SIT, UAT, Pre-prod environments, and Defect Tracking.

Environment: RUP, UML, Word, Excel, PowerPoint, Project, Visio, BPM, SharePoint, ADR, IBM Web Sphere, J2EE, BEA Aqualogic, Mercury Test Director, Mercury Quality Center, Test scripts, Test cases, Vignette, Lotus Notes