- Healthcare Business Analyst with 8+ years of experience in the Healthcare Industry on various areas like Claims Processing, Medicaid and Medicare Services, and Pharmacy Benefits Management (PBM).
- Over six years of consistent experience in the following areas: Ability to Elicit, Analyse, gather and document Business Requirements, System Change Document, Functional Specifications, 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.
- Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
- Experience with TriZetto Facets 4.21/4.31/5.01
- 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.
- Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820Companion guides.
- Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
- 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, Iterative, Incremental.
- Experience in Health Care Industry with exposure to Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems, Claims Processing, etc.
- Provide AGILE project management controls, project plans, timeline schedules, facilitate RAD sessions, and review software defects.
- Responsible for providing business requirements within an AGILE software development SCRUM environment.
- Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834 (Benefit Enrolment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 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)
- Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams.
- Contributing to software process-reengineering efforts aimed at evolving current software development practices to adopt Lean/Agile
- Analyzed, evaluated, researched, responded and resolved inquiries from Provider or Subscriber via mail, telephone and written correspondence involving benefits, eligibility and complex claims issues using the Claim processing systems of IRIS,NASCO,BlueCard and FACETS
- Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
- Adequate knowledge in Health Administration - Claim’s processing (auto adjudication), COB, EOB/Drafts, Claims pricing, enrolment, Medicare, MMIS, Medicaid, CDHP (consumer driven health plans).
- Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
- Experience with TriZetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
- Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
- Healthcare standards: HL7 2.x, CCD, CDA, FHIR and ICD-9/10.
- Experience in Mapping ICD 9 codes with corresponding ICD 10 Diagnosis and Procedure Codes.
- Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.
- Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
- Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
- Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
- Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.
- Ensure data integrity through effective configuration of fields and tables; proficiently review and correct 837 rejected files as well as evaluate 835 files to determine optimal solutions for creating payor matches.
- Strong Management and Communication Skills, demonstrated proficiency in leading and mentoring individuals to maximize levels of productivity, while forming cohesive team environments.
Project Methodologies: AGILE/ SCRUM, Waterfall and Rational Unified Process (RUP)
Project Tracking Tools: MS Project, JIRA, Rally, IBM Rational Clear Quest
Microsoft Tools: Word, Excel (Pivot Tables), Power Point, One Note, Outlook, MS Access
Database Tools: SQL Server, Oracle, PLSQL
Business Analysis Tools: UML, Balsamiq, MS Visio, Lucid chart, TopTeam, Tableau, SharePoint
Business Artifacts: Project Charter, BRD (Business Requirement Document), FRD (Functional Requirement Document), SRD or SSD (Software Specifications Document), Risk Management, Mockups, Use cases, Activity Diagrams and RTM (Requirement Traceability Matrix)
EDI Healthcare Transactions: 834 (Memberships), 835 (Payments from Payer), 837p (Professional Billing), 837i (Institutional Billing), 4010, 5010, 270, 271, 276, 277, 278
Healthcare: FACETS, HIPAA, NASCO, SHOP, Medicare, Medicaid, ICD 9, ICD 10, Claims Adjudication, RCM, EMR, EHR, COB and EOB
Confidential |woodland hills, CA
Senior Business Analyst
- Participating and organizing requirement gathering sessions with the stakeholders to elicit and analyse requirements.
- Assist in preparing Scope Document by analysing - various business domains interdependencies, end to end business processes of claims adjudication, various business domains scope statement, current business process flows and current system documentations.
- Working with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
- Wide-ranging experience in using methodologies such as UML (Unified Modelling Language), Agile, RUP (Rational Unified Process) & Waterfall using rational tools and Microsoft Suite.
- As Agile Scrum coordinated Sprints, from Iteration Planning thru daily scrum, and Iteration Reviews and Retrospectives.
- Following Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
- Maintaining knowledge of Medicare and South Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations
- Involving in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claim’s module.
- Involving in business analysis and project management, coordinating between the team members according to the business requirements.
- Strong HIPAA EDI 4010 and 5010 and ICD-9 and ICD-10 processes for member, payers, providers including Coordination of benefits, Co-pays, benefits and etc.
- Business analyst for collaborating requirements stakeholder for Medicaid system used JIRA as a tool to manage the requirements.
- Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
- Creating and maintaining procedures and documentation.
- Strong knowledge of Coordination of Benefits (COB), HL7 Standards, HIX, EHR - Electronic Health Records, EMR - Electronic Medical Records, CMS regulations, Health Care Reform, PPO, POS, MCOs and HMO.
- Organizing and conducted meetings, briefings, demonstrations, conducted JAD sessions, and wrote minutes of project meetings.
- Working with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.
- Actively resolving day-to-day technology needs of the business unit with a focus on the analysis of processes.
- Working with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
- Involved asNASCO representative for the planning of Requirements Managementand Traceabilityactivitiesand key advisory for the RequisitePro requirements management tool.
- Provide UAT support during Business Testing and validation support.
- Providing overall project management to multiple projects successfully completing them on-schedule and on-budget.
- Preparing the Business Workflow using MS-Visio with input, output, Pre and Post conditions.
- Working with the clients on the final signing process in the User Acceptance stages.
- Proven experience with Agile (Scrum) and Waterfall Development Life Cycles (SDLC) methodologies.
- Experience in testing the claims Adjudication Process using Facets 5.01.
- Worked on FHIR interoperability to consume data from hospital systems in real-time and feed into the LTPAC cloud for a 360 degree view of the resident all the way from SNF to Home Health Car
- Messaging, FHIR, middleware principles concepts, APIs, REST, SOAP, Web Services etc.
- FHIR messaging, structure and expertise in building complex event based real time interface.
- Preparing BRD (Business Requirement Document), HLD (High Level Design Document), SRI (System Requirements Inventory), RTM (Requirement Traceability Matrix) and also created BRC (Business Rule Configuration).
- Executed business process analysis “As-Is” system & “To-Be” systems & perform gap analysis.
- Working with all Facets Provider of software development from requirements gathering to testing, configuration, and deployment.
- Identification of problems found within FACETS 5.01 and when testing the SQL data database
- Wrote test cases and test scripts for the User Acceptance testing
Environment: Requisite Pro, Rational Rose, Agile, PL/SQL, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML, RUP, MS Excel, MS Word, MS Power Point, Visio.
Confidential, Irving - TX
- Engaged with clients to understand business processes and determine their specific requirements.
- Elicited and documented Business Requirement Document (BRD), Functional Requirement Document (FRD) and System Requirement Document (SRD).
- Developed, communicated, and validated requirements package with business and developers.
- Facilitated Joint Application Development (JAD) Sessions for communicating and managing expectations among the Stakeholders.
- Identified the Business processes for developing and documenting detailed business requirements.
- Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
- Made regular status presentations to senior management and walked the stakeholders.
- Worked collaboratively with Developers, Testers to perform a gap analysis of the company’s existing system functionalities.
- Validate EDI Claim Process according to HIPAA compliance and tested HIPAA regulations in Facets HIPAA privacy module.
- Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports.
- Tested the HIPPA EDI, 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.
- Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
- Validated the scripts to make sure they have been executed correctly and meets the scenario description.
- Extensively worked on all kind of joins and operators to fetch data from multiple tables.
- Worked with the client to create and execute the acceptance test strategy.
- Led and managed the User Acceptance Testing (UAT) for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
- Worked on FHIR conversion to be able to provide a 360-patent view from Hospital Discharge to Long-term Care, Home Health or Senior Living.
- Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
- Obtained signoff from project stakeholders on tasks completion
Environment: MS Office, Mainframes, Share Point, MS Access, Windows XP, Snag IT, Congas, Audit Studio, MS Office, HTML, ETL, XML, Data Warehouse.
Confidential, Irving - TX
- Requirements gathering from Subject Matter Experts, project stakeholders and Business users so as to obtain maximum details of requirements and involved in documenting Business Requirement Documents (BRD).
- Liaison between the Business needs (business users and sponsor) and the Technical team (development and testing staff), ensuring technical solutions satisfied business requirements.
- Conducted JAD sessions involving the management, development and user teams for clarifying requirements and facilitating better communication.
- Extensive knowledge of Medical Management Information Systems MMIS, Medicare, Medicaid and National Provider Identification NPI.
- Built strong knowledge of Healthcare Insurance claims processing systems (HIPAA Gateway, FACETS, NASCO etc.), EDI transactions, customer relation management (CRM), ANSI X12 codes, CMS rules and regulations, and Mandates and Guidelines of HIPAA compliance.
- Tasked with implementation of an improved Enterprise Requirements Management Program by utilizing industry and NASCO best practices to determine requirements processes, procedures and artifacts.
- Careful documentation of business requirements ensured that they are aligned with UI from the initial stage itself.
- Worked in Healthcare Claims Administration - Healthcare Claims.
- Processing (837/835) includes facility claims and professional claims.
- Participated in entering, tracking system defects in JIRA
- Familiarity with current technology and industry standards such as APIs, FHIR, JSON etc.
- Apply UML notations and methodology in developing models that accurately represent the business process and workflows and clearly communicate them to the stakeholders.
- Providedresearch andsystem analysis required for User Acceptance Testing(UAT)forthe integration ofstandardizedHIPAA(Healthcare Insurance Portability and Accountability Act) EDI transactionsand compliancythrough theNASCOclaims processing system for 40+ Blue Cross/Blue Shieldfacilities.
- Analyse EDI data elements captured by the existing system to validate it against the data elements required for new system.
- Was also involved in the configuration set up of provider reimbursement, benefit package, membership, and pricing in FACETS.
- Used MS SharePoint as the version tracking tool for managing the requirements documentation.
- Ensured that the claims processing is strictly under the HIPAA compliance regulatory document to safe guard patient information.
Environment: MS Visio, MS Office Suite (Word, PowerPoint, Access, Excel), JIRA, UML, HTML, SQL Server, Quality Centre.
Confidential | Tampa, FL
- Performed a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
- Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
- Analysed System flows of various department of the hospital.
- Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing.
- Identified risks, problems, requirements and concerns of the Hospital in order to comply with ICD-10 changes.
- Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
- Collected the information related to on-going application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
- Involved in Medicare, Medicaid and international classification disease (ICD 9 and ICD 10)
- Wrote SQL queries/joins for Oracle database and prepared test data.
- Re-Organized the collected data and prepared documentation for implementation.
- Involved in providing education about the ICD-10 codes and 5010 standards, its requirements, complexity and accuracy to Physicians and Nurses of the hospital. Figured out the requirement of training in various departments of the hospital based on their daily work.
- Performed impact analysis on applications for deadliness of ICD-10 conversion.
- Met the deadlines and scheduled day to day meeting sessions.
Environment: MS Visio, MS Office Suite (Word, PowerPoint, Access, Excel), JIRA, UML, HTML, SQL Server, Quality Centre.