- EDI Analyst with over 7 years of experience in Health Care domain with Claim adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
- Proficient in complete, RUP, WATERFALL and AGILE Client /server architecture providing a well - balanced understanding of business relationships, business requirements and worked for technical solutions to help the team at all levels until final product release.
- Experience onEdifecstools like Specbuilder, XEngine, XEServer, and Transaction management.
- Expertise in Information Technology/ Data/ Process Management with emphasis on Business Systems Analysis.
- Gathered good knowledge of Medical and Healthcare Standards and Regulatory vehicles such as HIPAA, FDA, ICD, MMIS, EDI, and HL7.
- Efficient in conducting workshops and Joint Application Development (JAD) sessions, Project meetings, Reviews and walk through sessions.
- Earned good knowledge in RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administrator, SQL Enterprise manager, data analysis and reporting.
- Expertise using MS Visio, Rational Requisite Pro for modeling and capturing business requirements.
- Excellent knowledge on 837i, 837P, 837d, 835, 834, 276/277, 270/271, 278, 820 HIPAA transactions.
- Experience in developing and imparting pre and post implementation training, conducting GAP Analysis, User Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis
- Experience in developing project plans using MS Project and MS Share Point, identifying documents, and validating requirements and reengineering process.
- Experienced in creating test plans, test cases, test results analysis with the testing team and reporting defect management and test status matrices.
- Experienced in Systems Testing, Integration Testing, and Software Quality Standards, Training, Documentation and implementation in a business environment.
- Excellent communication and presentation skills. Experience working with business users as well as senior management.
SDLC Methodologies: Agile, RUP, Waterfall, Rapid Application Development (RAD), V-Model
Requirement Management: MS Visio 2010, MS Office, Rational Requisite Pro, Rational DOOR, MS Paint
Project Management: MS Project 2010, MS Office 2010, Lotus Notes, MS Outlook
Presentation: MS PowerPoint 2010
Database: SQL Server, Oracle, Data Studio, MS Access, DB2Change Management Rational Clear Quest
Version Control: Rational Clear Case, MS SharePoint 2010 (MOSS 2010)
Operating System: Window XP, Window Vista, Window 7
Programming Languages: C, C++, HTML, XML
Data Modeling Analysis: Rational Rose, Power Designer 16, MS Visio, TOAD data modeler
Confidential, Baton Rouge LA
Sr. EDI Analyst
- Consulted BCBSLA Stakeholders on the use of 5010 Implementation Guides and Trading Partner agreements for EDI.
- Developed several baseline assessments for EDI, Privacy, and Security. Analyzed current business processes for areas impacted by HIPAA.
- Gathered Requirements separately for EDI and Web applications.
- Analyzed the requirements and created mapping specifications based on HIPAA implementation guidelines.
- Created inbound maps to convert and load from EDI ANSI X12 format into Database tables and flat files.
- Responsible for creating validation rules for HIPAA 837/835/997 onEdifecsSpecBuilder.
- Performed GAP analysis and converted maps from one version to another as per customer/business requirements.
- Created HIPAA compliant test data for 837 Institutional and professional claims using tools likeEdifecsSpec Builder.
- Gathered Reconciliation requirement and created Business Object Report spec for the internal Disease Management team.
- Involved in creating documents and diagrams for Membership Enrollment according to the HIPAA 834 Compliance Standards for Membership Enrollment.
- Involved with developing UML Designs, high-level business and technical requirements for 834, 824 HIPAA EDI Implementations.
- Identified the issues and done gap analysis with existing and current RDS Extract system for Reconciliation process.
- Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
- Tested theHIPPA EDI 834, 270/271, 276/277, 837/835transactions according to test scenarios and verify the dataon different modules.
- Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
Environment: OO Modeling, Web Sphere, Rational RequisitePro, EDIFECS, SQL, Rational Rose, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.
Confidential, Windsor, CT
- Production Support and Analysis of Defects related to Transaction sets 837/835 utilizing HP “QUALITY CENTER” Requirements/Defects MODULE, /EDIFECS.
- Release/deployment issues according to version management, backward compatibility, load balancing of components in production environment.
- Worked on 837 and 835 projects, including syntax and business rules for X12 HIPAA 4010 and 5010 validation for loops, segments, elements, qualifiers and code sets.
- Providing production support to EDI related issues originating from internal or external customer/Trading partners/Insurance payer/provider requirements.
- Worked with HIPAA compliant ANSI X12 834, 837, 276/277, 999 formats for both professional claims and institutional claims.
- Coordinating the upgrade of X12 Transaction Code Sets 277,837P, 835 and 834 to HIPAA compliance.
- Involved in claim adjudication process usingEdifecs/SpecBuilder and Quality Center/Transaction Manager application.
- Prepared Test Cases based on business requirements and business rules forHIPPA EDI Transaction 834, 276/277, 270/271, 837/835.
- Attending daily SCRUM and JAD Sessions and guided QA and Developers regarding the defects, Technical Specification Documents and Mapping Documents.
- Research, track, parse and interpret EDI files 999, Transaction Acknowledgement records, and enrollment and claims files inEDIFECSdata repository and UNIX server and analyze them according to the request.
- Work as a liaison between HP and Confidential and responsible for all the Cross Functional Communication.
- Validating the Log Files (999, x12,) for 834/820,277CA, 837IB and 835 Transactions in UNIX and HTM (Healthcare Transaction Manager
- Created technical documentation, Reviews, analyzes, and evaluated business systems for end user needs, including Companion Guides, business process reengineering, including GAP analysis and documenting requirements, documenting processes, workflows.
- Manually generated reconciliation reports using MS Excel and Access.
- Experience in understanding database structures and write SQL queries.
- Creative and aggressive self-starter with ability to handle ambiguity, able to communicate effectively with Cross Functional Teams at all levels, capable of delivering solutions under high-pressure environment
Environment: Facets, UML, Quality Center, MS Visio, EDIFECS, MS Outlook, DB2 Mainframe, UNIX
Confidential, Tampa, FL
- Gathered requirements by conducting meetings and brainstorming sessions with end users and Subject Matter Experts (SMEs) and documented them using Requisite Pro.
- Did Gap analysis on the ICD9 to ICD 10 conversion and subsequently the mapping between those.
- Prepared Business Requirement Documents (BRDs) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
- Requirement Specification for application development following the agile methodology.
- Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
- Worked on Unix Platform and experienced in back end testing by executing SQL Queries.
- Analyzed the laws and regulations (HIPAA, HL7) before implementing the electronic medical record software
- Reviewed Test Plans developed by the testing team for testing the application.
- Assisted the QA personnel in the creation of Test Cases using Rational Test Manager.
- Involved in performing version control and defect tracking activities using Rational Clear Case and Rational Clear Quest.
Environment: OO Modeling, Web Sphere, Rational RequisitePro, SQL, Rational Rose, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP.
Confidential, Tampa, FL
- Elicited demands from the stakeholders and analyzed them for consistency, flexibility and completeness.
- Conducted JAD sessions with Subject Matter Experts to obtain domain level information.
- Presented and conducted functional requirement reviews and walkthroughs with the designers, developers, and stakeholders.
- Identified Use Cases from Business Requirements and created UML diagrams like use case diagram and activity diagram using MS-Visio for various stakeholders.
- Used Query Analyzer, Execution Plan to optimize SQL Queries.
- Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
- Involved in resolving and documenting issues related to these EDI transactions including 834 transactions, 837 transactions using Test Director.
- Managed change request and analyzed the impact of change request on the application in regards to Project Plan, Project Scope, and Project Schedule.
Environment: Rational Unified Process (RUP), UML, SQL, Rational Test Manager, Rational Clear Quest, Windows, MS Office, HTML, Windows