SUMMARY

• 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.

TECHNICAL SKILLS

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

PROFESSIONAL EXPERIENCE

Confidential, Baton Rouge LA

Sr. EDI Analyst

Responsibilities:

• 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

EDI Analyst

Responsibilities:

• 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

Business Analyst

Responsibilities:

• 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

Business Analyst

Responsibilities:

• 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