PROFESSIONAL SUMMARY:

• 6+ years of consistent experience as Business Analyst with Payers and Providers in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, writing Use Cases. Proficiency in SDLC life cycle, ability to gather and document the 'As - Is' and 'To-Be' processes
• Requirement gathering through interviews, workshops, JAD sessions with stakeholders, developers and QA Analysts and referring to existing system documentation and procedures.
• Worked in a software development IT shop, created quality documentations such as Requirements Documents, Design Document, Test Plan, and User Acceptance Test Plans.
• Strong data analysis skills, experienced in data warehousing.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax such as ANSI X12
• Implementation and Knowledge of HIPAA code sets, 4010-5010 Migration, ICD-9, ICD-10 coding and HL7
• Thorough understanding and experience in Software Development Life Cycle (SDLC), and Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP)
• Extensive knowledge of Object Oriented Analysis and Design using UML, RUP, Rational Rose, Requisite Pro, Rational Clear Case, Visio.
• Accepted inbound /outbound EDI (X12) 837, 834, 820, 835, 999, 276, 277 transactions from multiple sources. Result oriented Joint Application Development (JAD) facilitator and meetings coordinator with excellent communication and interpersonal skills.
• Proficient knowledge and experience in Agile based business analysis and developing Vision, Software Requirements Specification, Supplementary Requirements Documents, Risk Mitigation Plans and Software Development Plans
• Efficient in translating Business Requirements into Functional and Non-FunctionalRequirementsusing UML diagrams and RUP Methodology
• Proficient in developing Business Requirement Documents (BRD) and Functional Requirement Documents (FRD).
• Strong experience and understanding of Strong knowledge and experience with claims associated with payers, claims by providers and member/subscriber claims.
• Strong knowledge of EDI Claims, member enrollment, and billing transactions.
• Understanding of HIPAA Standards and Compliance issues, HIPAA Privacy policy, opt in/opt out policy.
• Requirements gathering in compliance with HIPAA 4010 and 5010 standard.
• Experience web based application development and maintaining wikis.
• Good knowledge and extensively used RDBMS, Oracle, SQL, T-SQL and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Experience with healthcare fraud and abuse problem and solution development using Fair Isaac
• Writing Use cases and producing Behavioral diagrams (Sequence diagrams, Collaboration diagrams) and Class diagrams based on UML Methodology & creating Business process flow diagrams.
• Defining Test Cases, analyzing bugs, interaction with team members in fixing errors and User Acceptance Testing (UAT).
• Using project management tools like MS-Project for status reporting and planning.

TOOLS AND TECHNOLOGIES:

Methodologies: RUP, Agile, Waterfall

Requirement management tools: Rational RequisitePro.

Business Modeling: Rational Rose, MS Visio, MS Project 2010, SQL, PL-SQL, T-SQL,Oracle,SQLEM Software MS Word, MS Power Point, MS Excel, MS-Visio, XML, MS SQL Server 2008, SharePoint 2010, Data Warehousing Oracle, Quality Center, QTP, Rational Rose:

Healthcare Tools and modules: FACETS, QNXT configuration, Billing, Claims processing and submission.

TECHNICAL SKILLS

Confidential, Cincinnati, OH

Sr. Business Analyst

Responsibilities:

• Worked closely with Business Directors, project managers, business analysts and SMEs in various business areas to gather, analyze and document the requirements and supported the project throughout the development lifecycle.
• Responsible for gathering the requirements for the health processing system.
• Followed agile scrum methodology throughout the project.
• Developing Use Case Models, Entity Relationship Diagrams (ERD), Activity Diagrams, State Diagrams and Data Flow Diagrams (DFD).
• Gathered business requirements through interviews, surveys, and observing from account managers and UI (User Interface) of the existing system.
• Involved in business analysis and project management, coordinating between the team members according to the business requirements.
• Created and maintained procedures and documentation.
• Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level.
• Identified various business processes and developed process flow diagrams for the business processes and validated the processes with SME.
• Organized and conducted meetings, briefings, demonstrations, conducted JAD sessions, and wrote minutes of project meetings.
• Writing Use cases and producing Use Case Model, Analysis model, Behavior diagrams (Sequence diagrams, Collaboration diagrams) and Class diagrams based on UML Methodology & Business process flow diagrams using Visio.
• Using Rational Unified Process (RUP), Rational Rose, Requisite Pro, Software Development Life Cycle (SDLC) processes and methodologies
• Accepted inbound /outbound EDI (X12) 837, 834, 820, 835, 999, 276, 277 transactions from multiple sources. Result oriented Joint Application Development (JAD) facilitator and meetings coordinator with excellent communication and interpersonal skills.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.
• Performed testing of the health benefit claims receiving and processing system to ensure that the system adheres to project standards, performance criteria, and functional specifications
• Used Requisite Pro for managing requirements.
• Extensively worked with HIPAA 837, 834 and 835 files.
• Maintained Test matrix and Traceability matrix and also performed Gap Analysis.
• Participated in meetings with the developers on a regular basis to update the test documents.
• Identified and documented all issues and defects to ensure desired quality of the application functionality.
• Worked with development team members to better understand system functionality in order to improve testing quality.
• Analyzed and validated results of various FACETS tables involved in the batch process using SQL and PL SQL.
• Led integration efforts for Enterprise Provider repository and other source systems and MMS
• Facilitated requirements gathering for teams located across different US locations.
• Worked closely with Care Management, Provider connectivity, IT teams to gather, refine and implement solutions.

Environment: HP ALM, MS Visio, DB2, XML, UML, Rational Clear Quest, FACETS, HIPPA, SME, ERD, DFD, SQL, EDI, UAT, RUP, SDLC, UML,MMS, Windows OS, MS Excel, MS Word, MS Access, BRD, FRD, FSD.

Confidential

Business Analyst

Responsibilities:

• Acted as co work stream lead on Reporting creation and remediation efforts.
• Mapped business processes across organization into Flowcharts and re-engineered them for business process excellence initiative.
• Responsibilities include IT and Business remediation due to federal regulations, business process mapping, getting applications rewritten in .Net and Analysis for designing data warehouse and reporting requirements.
• Vendor communication and management and partnering with business and IT to gather requirements, build, configure, test, train and deploy solutions.
• Worked on defining the project schedule and creating the project plan during the initial stages of the ICD 10 project
• Worked on Facets configuration across Claims, Repricing, and Subrogation and Risk management.
• Reviewed the BRD to ensure the business deliverables scope and objectives correlate with the business requirements. Documented FRD based on the BRDs
• Produced detailed and structured BRDs including mockups (layout)
• Responsible for managing and validating bi-directional traceability between business and functional requirements for Change Requests (CRs).
• Created Flowcharts, Business and Technical requirements for ICD-10 project
• Consolidated and analyzed Interfaces, extracts, portals, reports and custom codes for all inbound and outbound files between vendors and the health payer, and remediated them for ICD 10 project.
• Designed surveys to collect information and coordinated Testing efforts across vendor spectrum for Facets implementation and ICD-10 conversion.
• Collaboratedwith QualityAssurance and Businessteam in proactively identifyingverificationchecks and validations for business processes, Functionality, documented them in usingHPQC.
• Developed SQL queries, functions, stored procedures and triggers to perform the backend testing of the data
• Extensively used SQL statements to query the Oracle Database for Data Validation and Data Integrity.
• Executed SQL statements to check if the data integrity has been maintained.
• Assisted Portfolio manager for Cost and Effort estimation for ICD 10 project.

Environment:Facets, Oracle, MS Project, MS Office suite, MS SQL, MS SharePoint, Oracle, TOAD, UAT, SQL, ICD, HIPAA, Clear Request, FSD, BRD, DFD, ERD, Sharepoint, Windows OS.

Confidential, Bronx, NY

Business Analyst

Responsibilities:

• Assisted the project manager in the creation of project charter & vision document during the inception phase of the project.
• Responsible Subject Matter Expert (SME)for developing NC Medicaid Application and Data Warehouse (Request for Proposal) RFP requirements used for Ad-Hoc Reporting, Statistical and Analytical Reporting including (Surveillance Utilization Review) SURs and Fraud and Abuse detection.
• Instrumental in Gap Analysis, RFP, RFI and Proposal writing, requirements gathering and analysis using Request-PRO
• Produced Activity diagrams with defined swim lanes as part of the claims process analysis.
• Translated business requirements into functional specifications and documented the work processes.
• Used TriZetto HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) standards.
• Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments.
• Modeled functional requirements using UML and MS Visio to create Use Case Diagrams, Activity diagrams, Sequence Diagram and logical Class Diagram for interaction between the various actors and system and to supplicate the Workflow Models.
• Developed Use Cases, workflow, screen mock-ups and conversion requirements. Followed UML approach to organize requirements and grouped into business processes, business rules, information needs and ensured that critical requirements are not missed.
• Clarified to claims personnel the new Affinity payments and Explanation for payments (EOPs) for same claim processing cycle.
• Clear understanding of Medicare (Part A, Part B and Part D) and Medicaid benefits.
• Assisted the QA in performing simple SQL queries for QA testing and data validation.
• Conducted user training pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity (mainly occur with EOPs, capitation rosters, PCP membership rosters, provider directory listings and some system generated letters).

Environment:HP QC, Oracle, MS Project, MS Office suite, MS SQL, Rational Suite, Citrix, MS SharePoint, Use Case Diagram, MS Visio, HIPAA.

Confidential, Richardson, TX

Business Analyst

Responsibilities

• Conducted surveys, interviews and JAD sessions and GAP Analysis for preparing a Business Requirement Document (BRD), Functional Requirement Document (FRD) and then translating it to functional specifications and test plans.
• Integrated RequisitePro with ClearQuest and Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests
• Managed all the requirements in RequisitePro, making requirements available to all team members
• Created requirements analysis and design phase artifacts using RequisitePro, Rational Rose
• Used the Unified Change Management from Rational to track changes to multiple artifacts by versioning artifacts, associating requirements to specific change request/defects to streamline the defect/change tracking process
• Assured that all Artifacts are in compliance with corporate SDLC Policies and guidelines
• Coordinated and prioritized outstanding defects and enhancement/system requests based on business requirements, allowing sufficient time frame to ensure accuracy and consider deadlines.
• Facilitated various brainstorming, requirement gathering sessions, and provided training on HIPAA Compliance, HIPAA Standard transactions and current version of X12 HIPAA 4010A1.
• Performed Data mapping on the extracted data, created class diagrams, ER diagrams and used SQL queries to filter data.
• Involved in the 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, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Designed and developed Use Cases and scenarios, Activity Diagrams, High Level and Low Level Process Flow Diagrams.
• Interacted with DBA for the process of data extraction, data transformation, data load, data integration and conversion processes using business intelligence tools on the Benefit Plan functionality.
• Worked with PM to prepare Project charter, Project plans, daily, weekly and monthly team deliverables for each phase, using MS Project. Served as a Peer review member to verify, validate and modify necessary changes made considering technical and business aspects.

Environment: RUP, CICS, Citrix, DB2, MS Excel, MS Word, MS Access, MS Project, MS Visio, GAP, HIPAA,RequisitePro, MS Visio, ClearQuest.