SUMMARY

• Highly motivated and result oriented wif over7 years of industry experience as Business/Systems Analyst and Data Analyst in Healthcare Industry.
• Excellent in Developing and evaluating business process Models.
• Proven success as a business analyst through teh years, providing a well - balanced understanding of business relationships, business requirements, and technical solutions.
• Deep understanding of enterprise data warehouses.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Experience in configuration of claims adjudication systems, me.e., Amisys, Facets, QNXT.
• Adequate noledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Deep understanding of HEDIS Reporting, Medical Record Abstraction, Quality Improvement, and Data Analysis.
• Extensive experience in conducting Market Research, Feasibility Studies, Data Analyses, Data Mapping, Data Profiling, Gap Analyses, Risk Identification, Risk Assessment, Risks Analyses, and Risk management.
• Good noledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining teh membership eligibility, billing experience wifin life and disability in health plans wif thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Deep understanding of enterprise data warehouses.
• Experience in ETL of data using SQL Server SSIS; migration of Data from Excel, Flat file, and Data analysis for correctness.
• Expertise in GUI testing, functional testing, performance testing, UAT, unit testing, integration testing wif teh extensive noledge of smoke testing, volume testing and stress/ load testing
• Solid understanding of Business Process definition, Risk Analysis and SDLC methodologies.
• Experience wif healthcare system, Medicaid and wif prime focus on claims adjudication, provider, eligibility and prior authorization.
• Proficient in teh implementation of productionchange managementtechniques and service delivery disciplines
• Professional experience in business analysis, operations management and development, design, documentation and testing.
• Extensive experience in reviewing and understanding of Business & Testing requirements and writing detailed Test Plans, Test Cases, and Test Scripts.
• Experience in implementing Microsoft Office SharePoint 2007.
• Advised management on improvement strategies, Competitive & Profitability Analysis.
• Exposure to Client/Server, Web Application developmental tools and Software development and design.
• Extensive experience in Testing, Manual and Automated using tools Win Runner, Load Runner, Quick Test Pro, TestDirector, Rational Robot or Web and Client/Server Applications & Mainframes

TECHNICAL SKILLS

• C#.Net
• VB.Net
• AS 400
• Goldmine
• SQL
• SSIS
• IDMS
• QTP
• MS Windows NT 4.0/2000
• Windows 95/98
• Windows XP
• MS Visual Studio.Net
• IBM WebSphere 5.0
• Power Builder 5 6.5 7
• Rational Rose
• UML 2.0
• RUP
• OOAD
• MS Visio and Visual Studio.Net
• Sybase SQl Anywhere 5/6
• Adaptive Server Anywhere
• Crystal Reports
• MSSQL 7
• Oracle 6 / 7.x / 8i / 9i
• Oracle - TOAD
• Informatica
• SharePoint
• Bbusiness Object
• ETL
• Cognos
• Erwin ODBC
• Visual Source Safe 6.0
• Cobol
• Source Off-Site
• Round-Table
• Win CVS
• NUnit.net
• MS Project
• MS-Office

PROFESSIONAL EXPERIENCE

Confidential, Columbus, OH

Business Systems Analyst

Responsibilities:

• Established teh business analysis methodology using Rational Unified Process(RUP) technique
• Helped develop project plans and to manage project scope.
• Preformed regular sittings wif stakeholders modeled system requirements through JAD/JAR sessions and maintained project stakeholder request baselines.
• Attended and conducted meetings and workshops to discuss high level requirements and developed User Requirements Specification Document.
• Designed and wrote a system to load membership (Medicare, Medicaid and Commercial) data to AMISYS Systems dat allowed for 10 distinct input formats and generated - add, change, terminate, reinstate - reports as a pre-load membership process for user reviewing.
• Worked on modules related to Providers, Contract & Claims and worked wif Claims, Provider attributes, enabling EOB & Remit rules associated wif Provider configuration process in QNXT.
• Installation of major components for teh Trizetto QNXT 3.4 medical record system including coordination of benefits for Dual Member and Dual coverage customers, Medicare Processing Refund, 837 EDI/ hardcopy claims input and 276/277 queries.
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT dat would take several man hours to complete via teh front end software.
• Created reports using Microsoft SQL Server 2005 Reporting Services and QNXT 3.4 tables
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT dat would take several man hours to complete via teh front end software.
• Assisted in building teh system analysis process model using Rational Rose.
• Identify, assess, and document system requirements, recommending business priorities, and advising business on options, risks, and costs.
• Performed Data Analysis and Data validation and data cleansing by writing complex SQL queries using SSIS on SQL database
• Performed System testing of teh Claims processing systems (Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment).
• Creating Test Case Scenarios for front end edits, Centres for Medicaid and Medicare (CMS) Quarterly mandates.
• Analyze impact of proposed solution across teh business, develop use cases to explain/demonstrate system requirements/specifications to IT team, and contribute a business and process perspective during design reviews.
• Implemented teh Rational Unified Process (RUP) in terms of disciplines and phases, each consisting of one or more iterations.
• Tracked and reported incomplete or to be completed next steps in teh SDLC (software development lifecycle) of various surround applications involved in Amisys Advance upgrade.
• Meant wif client weekly to report on status of issues related to teh Amisys Advance 6 enhancement project.
• Created DTS and SSIS Packages to vendors in which records were loaded Daily, also to other data resources such as Excel, Access, flat file, and XML in order to Create and maintain a centralized data warehouse.
• Involved in development & documentation of Software Requirements Specification (SRS) and using Rational Rose.
• Utilized PL/SQL (stored procedures, functions, packages and triggers) and SQL (queries) programming to create business logic
• Developed strategies wif Quality Assurance group to implement Test Cases in Mercury Test Director for stress testing and UAT (User Acceptance Testing
• Prepared scenarios, Use Cases & UML State Diagram for scenarios using Rational Rose.
• Created Use Case specifications, business flow diagrams, Activity/State diagram and Sequence diagram using MS Visio and object oriented (OOA/OOD) methodology.
• Conducted Joint Application Discussions (JAD), project meetings, reviews walkthroughs, client interviews and coordinating various technical team at off shore and managerial teams at all levels.
• Performed GAP analysis of business rules, business and system process flows, user administration, and requirements
• Provided strategic support in development of detailed project plans, work assignments, target dates etc

Environment: Visio, Ms Project, Ms Office, RUP, UML, Rational Rose, requisite Pro, MS Visio, PL/SQL, SQL

Confidential, MN

Business Analyst/ Data Analyst

Responsibilities:

• Studied business requirements and conduced User Interviews to identify and document teh data discrepancies and their sources as related to Government Contract Compliance (GCC), Government Disclosures, Government Pricing, Customers, Products, Product pricing.
• Responsible for developing applications for physicians' electronic billing and scheduling, and electronic medical records (EMR).
• Successfully handled teh testing of health care products like Epic Systems and EHR (Electronic Health Record).
• Used noledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Maintained existing Benefits configuration in AMISYS
• Supporting client’s HEDIS Processes and Reporting needs, and halping them to reach new levels of performance.
• Worked on requirements and completely developed teh new process for HEDIS data processing.
• After Executive confirmation did Gap analysis to assess needs dat could not be met by core EHR.
• Worked on Electronic health record system as a CRM web based application.
• Developed extensive experience in eligibility and benefits calculation for state, federal and local services such as Medicare and Medicaid.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Worked on Claims Processing per Medicaid Management Information Systems (MMIS) 42 CFR 433.
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
• Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
• Responsibility included modifications to a customer’s mainframe system to support new product features or regulatory requirements and, in some cases, involved a system upgrade.
• Performed pricing keywords and benefits analysis on claims pending for missing configuration scenarios in order to make corrections to processing logic in AMISYS.
• Converted Business Requirements to teh Functional Specification and Conducted JAD Sessions to develop an architectural solution dat teh application meets teh business requirements, resolve open issues, and change requests.
• Use Cases and other Process Flow Models were designed using Visio and Rational Rose.
• Helped in developing QA Test plans for Systems integration and System Testing. Performed Black Box Testing. Performed GUI testing and user acceptance testing (UAT).
• Identify Member, Provider, Coverage, Medicare, and Medicaid
• Worked on modules related to Providers, Contract & Claims and worked wif Claims, Provider attributes, enabling EOB & Remit rules associated wif Provider configuration process in QNXT.
• Worked on SQL Server 2005 concepts SSIS (SQL Server Integration Services), SSAS (Analysis Services) and SSRS (Reporting Services). finalized for development
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access.
• Reviewed Stored Procedures for reports and wrote test queries against teh source system (SQL Server) to match teh results wif teh actual report against teh Data mart (Oracle).
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Established a RUP (Rational Unified Process) centric business analysis methodology.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data wifin teh Oracle database.
• Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams and ER Diagrams in MS Project.
• Automated confidence tests dat run on new builds on regular basis.
• Managing overall testing process and project to production change management life-cycle.
• Involved in creating automated Test Scripts representing various Transactions, Documenting teh Load Testing Process and Methodology. Created meaningful reports for analysis and integrated teh Performance Testing in teh SDLC.

Environment: Windows 98/2000, Window2003, Window NT, Linux, Mainframe, Solaris IBM Web sphere, Load Runner 8.2, Oracle 8i/9i/10g, SQL Server 2000, DB2, Toad, MS-Project 2000/2003.

Confidential, Mars, PA

Business Systems Analyst

Responsibilities:

• Designed High level design, for New process, integrating wif legacy and Facets
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Planned and documented procedures for data processing and prepared data flow diagrams for teh application.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Followed teh standards of PMO which included getting approvals for SOX Compliance at various Gates.
• Prepared Functional Design Specifications employing Use case scenarios, sequence diagrams, ERD's, DFD's and class diagrams
• Gathered high level requirements and developed scope of teh project for teh implementation of Microsoft Office Share Point 2007.
• Claims testing of NASCO contracts via NPS system for different test claim scenarios and projects. Verify test cases for healthcare reform, changes in benefits are processing as expected.
• Conducted weekly meetings for deciding teh Policies and Procedures to be followed while constructing new sites.
• Recommended changes for system design, policies and workflow effecting Medicare Medicaid Claims processing system in compliance wif current government process like HIPAA and EDI.
• Monitoring of critical COTS services
• Performed teh requirement analysis, impact analysis and documented teh requirements using Rational Requisite Pro.
• Impact analysis and feasibility study of system to in corporate new functionalities in ETL
• Report daily to teh COTS Maintenance Manager to assist in any maintenance warranty issues.
• Actively involved in changing and upgrading existing system logic wifin teh NASCO
• Processing System (NPS) for all Blue Cross Blue Shield Control Plans.
• Worked wif HIPAA 270,271,835,837 transactions. Performed validation of 270,271,835 and 837 Professional and Institutional format files according to EDIFECS engine.
• Used SSIS to create ETL packages (.dtsx files) to validate, extract, transform and load data to data warehouse databases
• Business Requirements, Systems Requirements, Test Criteria, and Implementation to have teh outputs of project dealt wif teh automation of correspondence directed to Insurance policy owners
• Provide technical expertise as an early engagement to different modules and enhancements to access impacts and define scope.
• Generated database SQL scripts and deployed databases including installation and configuration.
• Formulated logical statements of business requirements researched and evaluated alternative solutions and recommend teh most efficient solution for system design.
• Review requirements and understand technical recommendations and constraints, and develop comprehensive and accurate functional specifications; Data Mapping, and process flows.
• Work wif Compliance and Regulatory operations to follow and monitor different IT process bound by CMS Regulations.

Environment: Windows XP, Business Objects, MS Excel, EDI, Word, Visio, Rational Clear Quest, Rational Clear Case, BPM, ETL, SQL Server SSAS SSRS SSIS, Facets, power point, COTS, SQL, NASCO, DB2, SAS database.

Confidential, Franklin Lakes, NJ

Business Systems Analyst

Responsibilities:

• Met wif various HMO, PPO, Medicaid/Medicare, and Tricare / Champus Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues
• Integrating systems of record into conformed dimensions and fact tables.
• Involved in analyzing teh claims on basis of Primary and Secondary Payers and performed Medicare subsidy eligibility check for employee group plans.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Prepared project plans using MS Project and coordinated timelines as guided by teh Project Manager
• Managed teh team of consultants responsible for developing on-demand Medicaid Management System reports.
• Conducted UAT; facilitated discussion between business team and QA team on determine teh test requirements and pass/fail criteria; documented and reported user feedbacks to management team.
• Prepared automated generic Test Scripts and Functions using Rational Robot for functional/GUI and regression testing
• Designed, developed and executed testing scenarios in order to implement 12 million-dollar provider settlement in AMISYS application. Resulting configuration ensured future claims submitted for payment by providers identified in settlement would not pay.
• Experience wif data migration (ETL development), document data manipulation processes and scripts
• Developed detailed use case models and supporting specifications.
• Involved in decision making of converting manual test cases into automated test scripts and analyzing their life time and time required to update teh scripts.
• Maintained and configured letters in AMISYS Correspondence Generator subsystem, ensuring lawful compliance wif CMS guidelines.
• Used Castor to create objects from XML documents. Involved in Logical & Physical Data Modeling. Database Schema design and modification of Triggers, Scripts, Stored Procedures in Sybase Database Servers.
• Reported and analyzed all application defects, user issues and resolution status to teh higher manager using Mercury Quality Center..
• Implemented data access, storage and validation routines on teh database server using Procedural Language/Structured Query Language (PL/SQL).
• Responsible to import teh data from Crystal reports by using Business Objects Live office into Microsoft Excel and Word.
• Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
• Created use cases, activity diagrams and process diagrams using Microsoft Visio.
• Validate test plans/scripts and perform final reviews of test results.

Environment: Rational Rose, Clear Quest, Microsoft Project, Crystal reports, SharePoint, Mercury, Lotus Notes, Erwin, Microsoft Visio, Microsoft Office suite, Business Objects, ETL, Oracle, Windows NT, Mainframes, COBOL.