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Edi Business Analyst/edi Qat Resume

Downers Grove, IL


  • 6+ years of consistent experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, System Change Document, Functional Specification, experienced in writing Use Cases. Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be'/’Go-To’ processes
  • Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820 Companion guides.
  • Requirement gathering through interviews, workshops, JAD sessions with clients, developers and QA Analysts and referring to existing system documentation and procedures
  • Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
  • Worked in a software development IT shop, created quality documentations such as Requirements Documents, Design Document, Test Plan, and User Acceptance Test Plans.
  • Requirements gathering and evaluation in compliance with HIPAA 4010 and 5010 standard.
  • Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements.
  • Strong experience with different project methodologies including Agile-Scrum Methodology, Waterfall, Modified-Waterfall, RUP.
  • Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834(Benefit Enrollment and Maintenance), 820(Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271(Explanation of Benefits (EOB)/Response to EOB), 276/277(Claim Status/Claim Status Response), 835(Remittance Advice and notifications), 837’s(Claim).
  • Experienced with mapping X12 formatted files to the flat file using the translator.
  • Proficient with various modules of IDX.
  • Proficient in writing test cases for both front end and the back end.
  • Proficient with mocking up data to test when actual test data are not available.
  • Strong experience and understanding of health care industry, claims management process, Knowledge of Medicaid and Medicare Services
  • Experience web based application development and maintaining wikis.
  • Experience with healthcare fraud and abuse problem and solution development
  • Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams
  • Creative and aggressive self-starter with integrative thinking skills, capable of forming and maintaining positive and productive working relationships in internal, external, independent, and team environments
  • Highly motivated, organized and results and detail oriented with excellent interpersonal, communication and presentation skills. Proven capability of adapting to new and fast changing technologies


EDI Tools: Foresight HIPAA Desktop Validator, Claredi, Foresight Test Data Generator, UltraEdit, UltraCompare, SeeBeyond translator.

Project Methodologies: Agile, Waterfall, Modified Waterfall, RUP

Business Modeling Tools: MS Visio, MS Project, Adobe PDF Factory

Requirement Management Tools: SharePoint, MS Excel.

Defect Tracking Tools: SharePoint Defect Tracking Tool, Quality Centre.

Operating Systems: Windows NT/XP/2000, Citrix, UNIX

Business Applications: Microsoft Office Suite, MS VISIO, MS Project

Others: MS Outlook, MS Communicator, MS Live Meeting.


Confidential, Downers Grove, IL

EDI Business Analyst/EDI QAT


  • Perform gap analysis between HIPAA and HIPAA Companion Guides
  • Perform gap analysis between HIPAA and HIPAA Companion Guides.
  • Perform impact analysis of other enrollment processing systems to determine potential scope/impacts
  • Performed thorough analysis of the companion guides from each trading partners both Medicaid and Commercial clients and identified the changes that specific clients need.
  • Review with business owners to identify data requirements and business rules based on the changes within the transaction set
  • Map the data according to the client requirement.
  • Provide dual usage processing capabilities to support both the 4010 and 5010 versions of the 834 transaction set to accommodate those clients who choose to remain on the 4010 version and for those clients who convert to the 5010
  • Monitor state communications to determine if states will be moving from proprietary formats to 5010.
  • Prepare Requirement Traceability Matrix, Functional Specification, System Change Documents, Technical Specification Documents, As-is and To-be flows for the entire conversion process.
  • Work with the commercial business owners as well as the state representatives in process of gathering the requirements.
  • Build a brand new translator for accepting the 834 and 5010 files and converting into the flat file layout.
  • Mapping the new data in 5010 to the translator to make it 5010 compatible.
  • After performing the thorough analysis, design the new translator based on the specific requirement from the commercial and state clients.
  • Tested the new translator to verify and validate if the input data is being translated correctly to the correct positions in the Flat file.
  • Maintained the dual usage functionality in order to received the 4010 formatted files for the clients who are not ready to switch to 5010 and 5010 formatted files that are willing to switch to 5010.
  • Prepared the common as well as the translator specific test plan for testing the new 5010 process flow.
  • Performed System Testing for the X12 formatted data that gets translated to the flat file through translator.
  • Validated the positions and the characters after the data gets translated through SeeBeyond.
  • Set-up the trading partners for receiving either 997(Functional Acknowledgement) or 999(Implementation Acknowledgement) and not both.

Environment: Windows 2003, Citrix, SeeBeyond, MS Office, MS Visio, .Net, SharePoint library, SharePoint Defect Tracking Tool.

Confidential, Nashville, TN

Sr. Business Analyst


  • Analyzed the requirements for Payment Integrity fraud and abuse solution to be developed
  • Worked on defining and implementing Clinical Aberrancy Rules
  • Prepared high level and detailed functional requirements documents for the clinical aberrancy rules
  • Involved in strategic planning and analysis of enterprise systems to assist in the healthcare fraud and abuse solution development
  • Prepared labor and cost estimates for clinical aberrancy rules development
  • Involved in meetings with director of analytics, project manager and other stakeholders to identify the cost associated, values delivered and break even time
  • Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
  • Identifying the requirements for accommodating HIPAA 4010 and 5010 standards for EDI X12 transactions and capture these requirements for mapping purposes.
  • Mapped the standard 4010 and 5010 elements to the associated Java classes for rules processing
  • Mapped the Bloodhound tool (clinical editing tool) related data elements to the internal XML elements.
  • Created the data dictionary for the clinical aberrancy rules
  • Defined input and output data elements to and from the rules processing engine
  • Analyzed the integration requirements between various tools for Payment Integrity solution
  • Write high level and low level integration requirements for integrating our product with clinical editing tools, predictive analytics tool and services
  • Work together with the architects and team responsible for supporting rules processing tools during the project to assist with the required support.
  • Identify and analyze the various points of integration for the new solution and required integration with other IT components
  • Work closely with the business team, development team and the Quality Assurance team to ensure that desired functionalities have been achieved by the application, monitoring the test cases and developing traceability matrix.
  • Provide business and technical suggestions and recommendations during the project life cycle.

Environment: Windows XP, Oracle, Java, ILOG, Clear Quest, MS Office, MS Visio, .Net, Quality Center, SDLC

Confidential, Virginia Beach, VA

Business Analyst


  • Worked on analysis of the Facets claims processing application in order to gather requirements to comply with HIPAA 5010 requirements.
  • Analyzed HIPAA 4010 and HIPAA 5010 standards for 837P, 837I and 835 transactions and prepared gap analysis document for each transaction.
  • Utilized RUP methodology during the project life cycle and worked together with RUP mentors at the location.
  • Wrote high level and low-level business requirements for the project.
  • Analyzed the existing data model and provided suggestions and recommendations
  • Worked with the solution architect in order to understand the existing data model and modify the data model to accommodate the required 5010 changes.
  • Utilized Mercator as an EDI mapping tool to map the claims data that passes through the EDI gateway to the Facets claims processing application.
  • Conducted meeting with the EDI team and other stakeholders team members to discuss the requirements
  • Involved in meetings with product manager, project manager, onsite and offshore team members to resolve issues and roadblocks during the project.
  • Involved in identifying the integration points within the organization as required for the project, involved in preparing test cases and UAT.
  • Provided business and technical suggestions and recommendations during the project life cycle.
  • Worked closely with the business team, development team and the quality assurance team to ensure that requirements are understood as intended in order to achieve the desired output.

Environment: Windows XP, RUP, Facets, Quality Center, .Net, Facets, SQL Server, Clear Quest, MS Office, MS Visio

Confidential, Raleigh, NC

Business Analyst


  • Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
  • Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
  • Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
  • Involved in defining and documenting the vision and scope of the warehousing project.
  • Worked with ACES and Facets claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
  • Involved in the development of Business and Technical Requirements Document (BTRD) and Business System Design (BSD) document for the project.
  • Involved in identifying and studying the ACES and Facets system data for the attribute mapping purpose
  • Conducted interviews with management team
  • Conducted and participated in the JAD session with the SME’s and project team members.
  • Worked as a liaison between the business and technical side to convey the business needs to the system architects.
  • Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
  • Designed Use Cases using UML and managed the entire functional requirements life cycle using SDLC.
  • Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
  • Carried out a thorough target data model assessment and risk analysis.
  • Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast changing environment to achieve company goals.
  • Participated in the walkthroughs and meetings specifically for Claims and Membership modules.
  • Coordinate with Development and Business team to develop high level Business and Technical documents.
  • Worked with the clients on the verification process for the requirement phase documents
  • Implemented Standardized process throughout the Software Development Life Cycle (SDLC).

Environment: Windows XP, Unix, Facets, Rational Requisite Pro, MS Office, MS Visio, UML

Confidential, Pittsburg, PA

Business Analyst


  • Responsible for captured the existing capabilities of the current Application X-Pack
  • Prepared a Reverse Engineering Business Process Document
  • Communicated with Business Stakeholders for Requirement Gathering
  • Established the JAD sessions with Clearinghouse System SME
  • Contributed in Technical Deep Dives for understanding the Business Processes involved in Clearinghouse System
  • Used SDLC Agile Methodology for the project
  • Prepared session with X-Pack developers to demonstrate the future X-Pack functionality
  • Used MS-Visio to draw Sequence and Activity Diagrams
  • Worked on ASC X12 Transactions sets: 834, 820, 270,271, 835, 276, 277 and 837
  • Wrote the Vision and Scope of the Project
  • Performed GAP analysis of as-is and to-be System
  • Checked the data flow through the front end to backend and used SQL queries to extract the data from the database.
  • Involved in writing complex SQL queries to extract the data from Oracle database
  • Performed UAT manually till user satisfaction.
  • Connected to SQL plus in UNIX and created and executed complex SQL queries.
  • Identified all Business Operations involved in Clearinghouse System
  • Validated all the Processes with X-Pack Experts, Technical and Development team
  • Documented Business Processes involved in Clearinghouse System
  • Created Summary Use Cases for next phase of Forward Engineering
  • Created Surveys for Existing Customers (Health Care Providers) to gather the future expectation of X-Pack Client like Institutions and Physicians
  • Extensive used of UML to draw Business Process Flow, Use Cases Modeling, Sequence, Sequential Diagram and Activity Diagrams
  • Assisted the business partner in preparing UAT plan/scripts and assured project manager has taken steps for alignment of Operational Quality Checklist
  • Assured entry/exit criteria are met for the different phases of testing (e.g., Unit testing defects closed before hand off to System/Integration testing, high severity S/I anomalies are closed before start of UAT, successful UAT prior to production deployment).
  • Wrote Test Cases, performed unit testing and integration testing
  • Analyzed test planning data using reports and graphs generated in Mercury Quality Centre
  • Worked on Mercury Quality Centre in setting up and Customizing Project entities for Defect Module Screens.
  • Worked as a Liaison between Stakeholders and IT department to fill the Gap by Using Simple UML Diagrams

Environment: MS Visio, MS Project, MS Office, SQL, Oracle, & PowerPoint, MS Word, MS EXCEL, UNIX, Windows

Confidential, Ewing, NJ

Business Systems Analyst


  • Gathered Business Requirements, analyzed data/workflows, defined the scope, and performed GAP analysis.
  • Met with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Functional Requirement Specification.
  • Involved in designing and developing Data-Flow diagrams, E-R diagrams, and logical and physical database design.
  • Facilitated collection of Functional Requirements from system users, and prepared Business and Technical Requirement Specification documents.
  • Helped manage risk analysis and mitigation plans, status reports, and client presentations; prepared business process models, defined milestone deliverables, and established critical success factors.
  • Gathered requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
  • Conducted UAT. Wrote SQL queries in MS Access and Oracle for data manipulations
  • Analyzed business and technical requirements, thus creating the Business Use Case (BUC) and Application Use Case (AUC) documents.
  • Responsible for writing Business Use Cases, Business Rules, logical analysis and change management of requirements.
  • Project lead (technical and functional) for stream: Correspondence. This covers various types of letters/mails/forms and checks that are dispatched from NJM premises to its policyholders and claimants.
  • Facilitated Joint Application Requirement (JAR) sessions to identify business rules and requirements with Business Teams.
  • Worked extensively with SMEs and performed Gap analysis to arrive at the gaps between current and future systems and the modules to be impacted.
  • Application was implemented in Agile Methodology (SCRUM).
  • Translated business functionality and opportunities into clear, precise and easy-to-read functional specifications, technical specifications with data mapping and application process flow and facilitated Joint Application Development (JAD) sessions with programmers.
  • Involved in creation of Data Dictionary describing data model of claim center database for WC Claims Integration and Reporting. Used Erwin to design conceptual, logical data model enforcing the data integrity and preventing use of redundant data within and between systems.
  • Wrote SQL Queries to create tables, stored procedures, triggers and performed data analysis, data mapping, data reporting using Microsoft SQL Server Management Studio.
  • Formulated integration test plans, test cases, test scripts and executed integration

Environment: Agile (Scrum), Rational Requisite Pro, WSDL, Erwin, SQL Server 2005, MS SQL Server Management Studio 9.0, Quality Center, MS Visio

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