SUMMARY

• An experienced Business Analyst / System Analyst with exposure Healthcare and Pharmacy.
• Experience in SDLC, Agile, Waterfall, Rational Unified Process, and SCRUM software development methodologies.
• Proficient at coordinating with stakeholders, vendors, Subject Matter Experts (SMEs), Project Manager (PM) and end users and elicitation of requirements through Joint Application Design (JAD) sessions, Brain storming sessions, interviews, Surveys and questionnaires, prototyping, benchmarking, Requirements workshops, document analysis, Joint Application Requirement (JAR) sessions and Rapid Application Development (RAD).
• Skilled in gathering and converting User Requirements into High Level and low level documents (HLD/LLD) like Business Requirements (BRD), Functional Requirement Documents (FRD), Functional Requirement Specifications (FRS) System Requirement Specification (SRS) and visualizing graphical user interface (GUI) using mockup screens.
• Expertise in Gap Analysis, SWOT analysis, risk analysis, cost - benefit analysis, feasibility analysis, and impact analysis.
• Experience with health care systems: QNXT, Medicare Part A, B, C, D, Medicaid systems, Technical Report Type 3 (TR3) Implementation Guide, and Companion Guide.
• Experience in configuration of claims processing applications, claim adjudication process, claims management process, real time claims adjudication, Electronic Medical Records / Electronic Health Records (EMR/EHR) and Medicaid Management Information System (MMIS), and Medicaid Information Technology System (MITS).
• Have knowledge of HIPAA transaction and code standards and electronic data interchange (EDI) standards like X12 837, 270, 271, 276, 277, 278, 835, 275 and knowledge of claims encounters process.
• Communicated effectively with the team members, stake holders and remained a focal point of contact for any issue resolution with respect to the requirement and testing of the application.
• Proficient in creating and managing Use Cases, User Stories, Test cases, Test plans, Test reports, Test scripts.
• Skilled at performing User Acceptance Testing (UAT), handling Change Request, and Configuration management.
• Used tools like JIRA and RALLY to create and maintain Product Burn-down chart, Sprint Burn-down/ Burn-up chart

PROFESSIONAL EXPERIENCE

Confidential, Milwaukee WI

Business Data / System Analyst

Responsibilities:

• Worked on implementation of new markets with defining and managing the scope of new systems requirement.
• Responsible for the development and maintaining EDI Data Mapping documents 277, 835, 837.
• Responsibilities include developing and documenting requirements, ensuring all compliance standards aremet, coordinating testing, evaluating and identifying possible application system issues
• Create, maintain, and organize backlog of features, epics, stories, and tasks in JIRA.
• Validated Inbound and outbound 837 transactions, including loading and correcting any errors with the process of EDI outbound files.
• Execution of Weekly and Monthly reports and processes and the creation of ad-hoc reports.
• Validated and Created queries for the analysis of data relating to claims, members and providers.
• Involved in Source Data Analysis, analysis and design mappings for data extraction.
• Responsible for maintaining HIPPA validation for 837 outbound files for various markets (Washington DC, Washington State, Kentucky, Virginia Anthem, Virginia CCC+)
• Helped in the implementation process while tailoring test plans to client use cases and configurations.
• Lead validation work sessions with the client.
• Demonstrated strong competency across the product suite and in providing best practice configuration recommendations or adjustments.
• Have worked in coordination Data Integration, Standardization, and Configuration teams to resolve issues with client products/results.
• Following the protocol/procedure to use a web-based platform to notify all close contacts of their exposure, determine the presence of symptoms, refer for testing if indicated, and provide appropriate quarantine education and guidance.
• Performed User Acceptance Testing for the ANSI X12 Version 5010 / EDI transactions (HIPAA) for Claims Status and Eligibility (277, 837P, 837I, 837D, 835 remittances and NCPDP Claims).
• Remediated errors received from state for different markets for claims with missing segment elements.
• Performed Data mapping to validate and customize Claims daily load into FACETS for processing the transactions.
• Conducted Requirements Clarification Sessions with concerned project members to clarify requirements.
• Good interpersonal skills, committed, result oriented and hard working.

Environment: Facets, Jira, MS Sharepoint, MS Visio, SQL, Oracle, MS Access, MS Excel, MS Word, MS PowerPoint, Notepad++, Ultra Edit, DBeaver.

Confidential, Fort Worth, TX

Sr. Business Analyst

Responsibilities:

• Prepared scope of the project and developed new business process along with process mapping and user task analysis. I also evaluated documentation analysis and business process analysis to identify the problem with existing system and find out new and advance way to develop business process, which was able to make the process more accurate.
• Worked on Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
• Worked on claims, Claim adjudication Membership, Eligibility.
• Worked with developing team to create advance claim submission process for Medicare and Medicaid patients as well as EDI transaction such as: 837 (P, I, D), 835, and 276/277.
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Conducted JAD session with business side to identify and gathered high level requirements and evaluated the priority level on the basis of meeting discussions and comments on requirements.
• Developed a vision plan that defined the primary goals and objectives of the project. Analyze user stories and segregated them into high level and low level.
• Providing day-to-day support to financial institutions which include responding to customer inquiries related to web-based software applications issues while ensuring customer expectations are exceeded.
• Utilized corporation developed Agile SDLC methodology used scrum work pro and Microsoft office software to perform required job functions.
• Wrote various SQL queries to create, update, modify tables, create reports and retrieve information from the database. Derive the required data by SQLs and export into Excel files
• Developed user guides, provides user training, and supports the user in development of work processes.
• Supported UAT to evaluate the system performance and also developed system plan to quality center, review design, view test cases.
• Generated reports for quality metrics using SQL Queries.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: SQL Server, Windows XP, Clear Case, Clear Quest, UML, Java, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access, XML.

Confidential

Business Analyst

Responsibilities:

• Involved in updating and/or reworking previous documentation on their Membership Enrollment System for Florida to get them in sync and up to date with their current new system in place.
• Involved in System Integration, Compliance and User Acceptance Testing and Validation of Medicaid claims processing and Electronic Data Interchange (EDI) translation in compliance with the 5010A Health Insurance Portability and Accountability Act (HIPAA) transactions 837 I/P.
• Analyzed the gathered requirement and reviewed Business Requirement Document (BRD) /Functional Specification Document (FSD)
• Utilized corporation developed Agile SDLC methodology used scrum work pro and Microsoft office software to perform required job functions.
• Reviewed and streamlined existing CRM processes, information, and data requirements to ensure accurate adoption metrics reporting. Deactivated users to release licenses. Analyzed if the system abides HIPAA regulations as portal displays member's private information. Performed data analysis and ran various SQL queries to critically evaluated test results.
• Gained understanding of Medicaid policy and billing requirements and documented needed changes to policies and billing manuals related to ICD10 through facilitation with internal KMHP program areas.
• Creating artifacts such as URS, FRS, Traceability Matrix, project plan, BRD, test plans, and test cases.
• Involved in Processing 837 Healthcare Claims (Institutional &Professional) in PORTAL.
• Documented business needs for ICD10 resulting from the HIPAA 5010 gap analysis.
• Used requirement elicitation techniques such as JAD Sessions and Document Analysis to gather information regarding the application from the KMHP SME and EDS along with the State of Florida people.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA 5010 code sets, ICD 10 coding and HL7.
• Experienced with the HL7 data transactions.
• Performed activities to comply with annual HEDIS data collection and analysis, preparing recommendations to increase rates as appropriate.
• Conducted meetings with the project managers to review the project plans.
• Recommend best practices for project plans to the project managers for their successful implementation.
• Involved in testing Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.
• Carried out UAT by developing test plans, test scenarios, test cases, and test data to be used in testing based on business and user requirements, technical specifications of the product.
• Involved in bi-monthly Technical and Operational Issues (T&O) Conference Calls with AHCA, EDS and various providers who worked with AHCA to answer and resolve issues pertaining to a smooth transition from AHCA's previous fiscal agent ACS to EDS.
• Maintained open and clear communication with the team on change requests.
• Determined the requisite training for both internal staff and Medicaid provider groups and assisted in the development of training materials.
• Maintained project documentation in a central repository and created a weekly report on the updated project plans and maintained them.

Environment: Agile, Jira, MS Paint, MS Word, MS Excel, 3, MS PowerPoint, MS Visio, SharePoint, ETL, RTM, Excel.