SUMMARY

• Over 9 years of extensive experience as a Business Analyst and EDI Analyst with strong experience in Healthcare Claims and Benefit Enrollment Process and Maintenance.
• Experiences working with HIPAA ANSI X12 both 4010 and 5010 Versions.
• Excellent understanding of ICD 9, ICD 10, CPT.
• Solid Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid, Claims/Billing, EDI transactions.
• Medical Claims experience in Process Documentation, Analysis and Implementation in HL7, EDI X12, 835, 837, 271, 277/997 (X12 Standards) processes of Medical Claims Industry from the Provider/Payer side.
• Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
• Knowledge on RCM (Revenue cycle management) and Revenue Cycle.
• Extensive experience in Healthcare/Claimsadjudication with knowledge of industry compliance standards like HIPAA and HL7, EDI X12 transactions (834, 837, 835, 270/271, 276/277).
• Experience with QNXT 3.4, QNXT 4.6, Facets 4.71, Inbound & Outbound interfaces, EDI configuration, and data mapping using ANSI X12 4010 and 4,835,837).
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Expertise in creating prototypes and mock - ups for user interface designs.
• Specialized in creating UML Diagrams like Use Case, Activity and data flow diagrams using Rational Rose and MS-Visio and consistently translate business requirement into IT solutions.
• Expertise in RDBMS concepts and running SQL queries.
• In-depth knowledge and experience in full SDLC with RUP, agile and waterfall methodologies.
• Created Business and functional requirement documents for the conversion process.
• Designed and developed scenarios based on business requirements.
• Familiar with QA, QC, JAVA AND JIRA.
• Involved in Functional System Testing, Integration Testing, Regression Testing, and UAT
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Experience analyzing environments with multiple data sources and capture necessary data requirement
• Extensive experience in claims adjudication with a solid understanding ofBusiness Processes Flows, BusinessAnalysis, Requirement Analysis and Business Modeling and Use Case development using UML methodology.

TECHNICAL SKILLS

Modeling Tools: MS Visio, Rational Rose

Methodology: Agile, Waterfall.

Testing: Quality Center, Test Director, win runner.

Programming Languages: C++, Java, JIRA, XML, HTM

Platforms: Windows, NT/95/98/2000/XP/Vista/Window 7. Linux

Industry Standard: HIPAA, ISO, HL7.MS word, MS Excel, MS Access, MS Power point, MS Outlook, Adobe

PROFESSIONAL EXPERIENCE

Confidential, Chicago,IL

Sr. Business Analyst & EDI Project Coordinator

Responsibilities:

• Gathered Requirements and created process flows for Premium Payments (Billing) and Member Services.
• Performed Gap Analysis for Marketplace in regards with the Medicaid system in place.
• Participated and facilitated JAD sessions to enhance requirements and create use cases and test cases.
• Worked alongside Enrollment team to structure the premium payments based on the federal and state guidelines.
• Performed Federal regulation sweepsand identified impacted areas and interdependencies.
• Designed and documented Business Requirements (BRD) by using ASCI X12 EDIguides, reviewed and interviewed business process owners and companion guides.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD 10Code set andANSI X12 5010formats.
• Involved in Processing QNXT 837, FACETSHealthcare Claims (Institutional and Professional) in PORTAL with valid TPI.
• Involved in testing QNXT Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.
• Great knowledge of EDI (Electronic data interchange), 834 and 837.
• Worked through Agile framework with Iterative process and sprint cycles.
• Identified various call types for member services based on the call volume for Medicaid system in place.(ID card request, Benefit clarification,PCP change, network adequacy and others).
• Identified and created SOPs and training necessities for the CSRs.
• Tested the HIPPA EDI 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data on different modules.
• Worked on team support RCM (Revenue cycle management).
• Created Inbound and Outbound call scripts for Member Services.
• Creating a Work breakdown document (WBD) to identify specific tasks for the call center operations of the Marketplace project along with the management team.
• Responsible for conducting and analyzing the impact analysis of the conversion from ICD-9 to ICD-10.
• Good knowledge of HCPCS/CPT coding formats and modifiers.

Confidential, Phoenix AZ

Sr. Business Analyst

Responsibilities:

• Gathered clinical data to perform workflow analysis and create system design
• Designed and built Smart Sets, Smart Texts, Smart Lists, Preference Lists, Built Smart Phrases with embedded Smart Links
• Created various labs/medication workflow rules, Content built/support charting tools for end users
• Configured and maintained Epic model Securities, Profiles, Roles, created EMP and SER records
• Troubleshoot daily PRD issues, in basket, charts and profiles
• Used the Dark/Text side to build and maintain Profiles, roles, security, message types, reports, print groups
• Worked with Chart review, results, encounters, programming points. etc.
• Participate in multiple end user acceptance Testings’ and provided support for end users
• Worked on XML / XSLT code writing and XML parsing.
• Analyze, configure and test workflow engine rules
• Assisted in the workflow analysis process to tailor functionality to departmental needs
• Experienced with configuring Edifecs Map Builder, and worked on trouble shooting XEngine.
• Worked with Edifecs (v 6.0 and higher) configuration
• Ensure proper work flows through dress rehearsals and validation sessions
• Lead and participated in continuous improvement initiatives and championed the effective implementation of process improvements.
• Participated with all phases of implementation, workflow, curriculums and lesson plan development; practice scenarios, and testing.
• Managing the development of a test plan
• Involved in Regression Testing
• Lead effort in writing and/or reviewing test scripts, identifying scenarios and executing test scripts, escalating issues to team leads and/or Manager
• Provide application test support to the teams during unit, super user and systems integration testing
• Provided system building in training environment
• Set-up User Security Classifications and User Roles for “Go-Live”
• Built Preference List, Smart Text, Letters with imbedded text and any Heat Ticket request from the end-users.

Confidential

Business Analyst 

Responsibilities:

• Presented clear and concise EPIC functionality:
• Creating EMP and SER records, Navigator usage, Orders and Order sets, Smart list, Smart sets and Smart phrase usage, flow sheet functionality/ CPOE, Troubleshooting workflow problems
• Participated in integrated system testing as assigned/ performed multi-level testing with responsibility for analysis of results and resolution of problems
• Developed detailed procedural materials for users and operations to support effective use of the EPIC application
• Was responsible for observing department workflow and data collection from the department to prepare for Ambulatory go-live
• Creating detailed requirements from a Developer perspective, low level design at the component level for different healthcare HIPAA transactions
• Was responsible for conducting system demonstrations for end-users and aid trainers during User training
• Collaborated with user departments to ensure projects and requests are prioritized and completed in a timely and satisfactory manner
• Participated in conducting Order transmittal mapping to ensure smooth work flow and efficient delivery
• Assisted physicians and nurses in workflows and showed them how to use Smart Phrases, Smart Lists & SmartText,
• Document Patient information, Placing orders, Entering back office Results, Telephone Encounters Using and building Smart Sets,
• Managing Encounters, Smart links and Med Sig Smart Phrases / Trained the trainer sessions/ Troubleshooting workflow problems. Participated in Epic Ambulatory Go-Live
• Educated and assisted the physicians on how to document encounters, manage their In-basket, orders, preference list and efficient use of Smart sets, and close encounters
• Assisted Clinician on how to document orders results
• Assisted cadence users to do the scheduling
• Assisted floor super users on issue resolution such as adding more activities to their Navigator and sending ticket to the commander center
• Lead effort in writing and/or reviewing test scripts, identifying scenarios and executing test scripts, escalating issues to team leads and/or Manager
• Provide application test support to the teams during unit, super user and systems integration testing
• Supported Physicians and Nurses during implementation and go-live
• Elbow to elbow support of Physicians during their rounding time, provided guidance in resolving issues with Orders and procedure.
• Assisted Physician and Nursing staff with patient list creation, unit support in entering vitals, review CPOE, Order and “Order set” functionality
• One on one Physician support, escalated issues to analyst, assisted Patient vitals/ Smart set functionality support.