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Sr. Healthcare Business Analyst Resume

Marietta, GA


  • An IT Professional with over 8+ years of Experience as Business Analyst/Scrum Master in Healthcare and Insurance Domain with strong knowledge of Business Analysis, Requirement Gathering, Agile scrum and Joint Application Development Methodologies with clients and referring to accessible documentation and procedure.
  • Experienced in client interaction, deep understanding of business systems functionality and technicality.
  • Experience in developing project plan and estimating project timeline.
  • Engage with clients, gather requirements, understand, analyze and customize the requirements as per the client’s business needs and development teams
  • Excellent working knowledge in Project Life Cycle and clear understanding of Project Management.
  • Hands - on experience in writing & reviewing User Stories, Use Cases, Test Cases, Business Requirement Documents (BRD), Functional Requirement Documents (FRD) and tracking and managing Requirement Traceability Matrix (RTM) and activity diagrams.
  • Perform UAT testing to ensure all business requirements are covered
  • Managing change requests related to working project plans daily to meet the agreed deadlines
  • Co-ordinate with development team for testing and implementations for various releases
  • Performing Gap analysis to define as is and to be processes. Suggesting changes to the product development team(CRP)
  • Functional Knowledge of Medicaid Management Information System MMIS.
  • Strong exposure to Medicare and Medicaid systems for inpatients, outpatients, Reimbursement Methodology.
  • Extensive Knowledge in the Member Enrollment and Billing information.
  • Knowledge and Experience on Membership, Billing, Claims Payment Processing in relation to HIPAA, EDI 4010, ICD-9, ICD-10, EDI Sets 270, 271, 834, 837,835.
  • In depth knowledge of Software Development Life Cycle (SDLC) methodologies such as Waterfall, Agile, and RUP.
  • Experience of Facet Implementation and conversion of 4.21.
  • Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrollment).
  • Proficient in Developing and executing Test Plans, Test Case, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
  • Extensive Experience in Functional, Integration, Regression, User Acceptance UAT, System.
  • Experience on working with ETL Tools to Extract, Transform and Loading data into a data warehouse.
  • Executed SQL queries for testing and report/data validation
  • Excellent knowledge of Epic Build, Epic Clinical Workflows, Epic Implementation, Revenue Cycle, Provider, Professional, Facility, COB, Medicare/Medicaid Claims, HL7 Interface Messages, Split Claims, Medical Necessity, Dual Coding, TA1 EDI Transactions, EOB, EOP, Claim Adjudication, FACETS & NASCO User Interface
  • Involved in various Facets Data models like Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice, Benefits, Product and Plan
  • Created and maintained requirement documents for Facets for the different modules like Billing, Member enrollment and Claim adjudication
  • Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry (270) and designed, analyzed and performed integration and wrote system requirements on FACETS
  • Set claims processing data for different FACETS Module and used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.


Methodologies: Waterfall, Agile, Rational Unified Process (RUP) and JAD.

Office Suite: MS Word, MS Excel, MS PowerPoint and MS Outlook

Project Management: JIRA, Confluence, Basecamp

Wireframing: Balsamiq

Business Modeling Tool: MS Visio, Rational Rose, Irise, Justin mind

Data Base: SQL, MS Access, Oracle, DB2

Operating System: Windows XP/Vista 2000/98/95

Software Application: Data Warehouse, ETL, Facets

Domain Knowledge: HIPAA, Medicaid, Medicare, Claims Management, EDI Transactions, Telecommunication, Data Services


Confidential, Marietta, GA

Sr. Healthcare Business Analyst


  • Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
  • Performed Cost benefit, ROI and ROM studies.
  • Conducted user interviews and documented business and functional requirements.
  • Performed Requirement Analysis and developed UML Use Cases, Activity Diagrams using Rational Rose to understand the requirements.
  • Worked with the management for improving and giving new ideas for designing future processes of the HIPPA transactions dealing out with EDI’S 271, 276 and 270, 470, 835, 837, 834, HIPAA 4010, 5010, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles and also well versed with ICD10, Facets.
  • Completed the documentation of Claims Scenario’s for the source system
  • Analyzed the existing claims process and specific business rule logic will be applied in the requirement model.
  • Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
  • Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
  • Created use case scenarios and documented work flow and business process.
  • Documented requirements associated change requests with requirements and connected requirements with Use cases.
  • Understood the requirements of the Sales and Marketing team
  • Developed gap analysis and risk assessments for theFACETSupgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
  • Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time transactions like 270/271/276/277 for Medicare and Medicaid programs inFACETS.
  • Performed extensive data modeling to differentiate between the OLTP and Data Warehouse data models
  • Designed the UI of the application, prototyping and wire framing in MS Visio for better illustration of the application.
  • Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
  • Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
  • Served as conduit for managing system requirements between the business and the software development team.
  • Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.

Environment: Hybrid, Windows XP Professional, Oracle9i, MS Access, MS Excel, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case, Rational Clear Quest, MS Office suite, MS Visio.

Confidential, North Chicago, IL

Healthcare Business Analyst


  • Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.
  • Gathered high-level requirement for all the external projects in a release.
  • Performed the requirement analysis, impact analysis and documented the requirements.
  • Conducted weekly meetings for deciding the Policies and Procedures to be followed while developing new site.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
  • Performed Analysis on Data mapping between different data models.
  • Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.
  • Created ICD-9-CM/ICD-10-PCS comparison document and dealt with DRGs.shift through CMS files.
  • Documented ICD9 to ICD 10 mappings one to one/one to Many according to the GEM files from CMS with the functional and structural changes related to the conversion to implement ICD-10
  • Worked on EDI transactions: X12, 835, and 837 P.I to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes
  • Executed the test cases and test scenarios using HP Quality center QC.
  • As a Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming session, daily scrums, product demos, sprint reviews and sprint retrospectives and maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.
  • Worked on theEDI 834-fileload toFacetsthrough MMS (Membership maintenance sub-system)
  • Worked withFACETSedits and EDI HIPAAClaims(837/835/834) processing.
  • ICD 9 - ICD 10 Conversion Project- Worked in the analysis of theICD 9 - 10codes conversion Project.
  • Created various reports such as billing payment reports, Billing Grouping Payment and discount reports
  • Use HP Quality Center to house all test documentation and report/track all issues and defects Defect Management.

Environment: Rally, MS Visio, HP QC, UML, MS Office, SSRS, HIPPA, EDI

Confidential, Philadelphia, PA

Healthcare Business Analyst


  • Analyzed business processes and worked with management and improved and implemented the solution to ensure compliances.
  • Coordinate with stakeholders and project manager to gather functional and non-functional requirements during JAD sessions.
  • Performed a High-level analysis of the requirements from a business perspective to determine the feasibility of constructing the new application.
  • Performed gap analysis to define As Is and To Be scenarios of Old MMIS and New MMIS.
  • Propose strategies to implement HIPAA 4010 in the new MMIS system and eventually move to HIPAA 5010
  • Created BRD,FRD Documents and Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, that include Functional and Non-Functional specification to hand off to development teams.
  • Served as a Relationship between internal and external business community Claims, Billing, Membership, Customer service, Healthcare Management and the project team.
  • Used HIPAA 5010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDIs 837, 835, and and ICD-10 code sets.
  • Recommend on implementation of HIPAA 5010 (EDI X12 837,834, 820, 278,270,999) in the new System.
  • Performed GAP analysis for EDI transactions such as 837, 834 to support state specified X12 5010 file formats.
  • Gathered requirement onFACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
  • Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
  • Executed Test cases manually by composing 270, 276, 837 EDI files and dropped inbound and check response 271, 277, 835 using interleaves and outbound.
  • Assisting the project manager in creating the business case and project plan.
  • Managed requirements in the various stages through Requirement Traceability Matrix RTM defining each technical requirement in detail.
  • Assisted in Conducting UAT User Acceptance Testing to make sure that all the user requirements are catered by the application.
  • Involved in preparing a simple and detailed User Manual for the application, for an intended novice user.

Environment: Rational Unified Process (RUP), MS Office, MMIS, MS Visio, SharePoint, SQL, Lotus Notes, Rally. Rational Tools


Business System Analyst


  • Attended meetings with stake holders and managers regarding process plans, functionality and business processes.
  • Participated in developing Product backlog along with product owner.
  • Developed Mockup and wireframes for new web feature.
  • Designed and developed various UML diagrams like Use cases, Activity Diagrams, Sequence Diagrams using MS Visio.
  • Consistently tracked the project status and reported it to all the stake holders involved.
  • Negotiate with functional managers and/or organizational management to obtain adequate resources with appropriate skills to staff the project team.
  • Have experience in interacting directly with key business users and geographically dispersed stakeholders.
  • Conducted Joint Requirements Planning (JRP) and JAD (Joint Application development) Sessions as a Facilitator to gather requirements from the group.
  • Participated daily standup meetings with the Developers.
  • Facilitated user interviews and workshops to gather requirements.
  • Involved in GAP Analysis and Technical Feasibility study with the technical leads.
  • Created process flow diagrams in MS Visio.
  • Worked with other team members for requirement analysis and clarifications and recommending changes for the gaps identified.
  • Defined web service interfaces, specifications and test scenarios for each service that will provide common enterprise functions for key business domains.
  • Extensive data validation on the back end using SQL queries to verify the data has been loaded in the correct tables.
  • Performed root cause analysis on complex data anomalies and working closely data stewards to define best practice.
  • Translate highly complex concepts and conclusions in a clear and concise manner in ways that can be understood by a variety of audiences.
  • Lead and own the analysis of highly complex data sources, identifying trends and patterns in data and make recommendations based on analysis results.
  • Participated in SCRUM meetings and worked closely with the Subject Matter Expert and the Project Manager.
  • Handling the Business-critical tickets using remedy tool.
  • Updating the Remedy ticketing tool regularly to reconcile critical issues.
  • Reviewed test cases and maintained the Requirement Traceability Matrix (RTM).
  • Used power point presentations for conduction walkthroughs with the stakeholders.
  • Coordinated and participated in User Acceptance Testing (UAT) to test the functionality of the application and worked with QA together to develop test Scenarios and test cases.

Environment: SQL, Atlassian Jira, SharePoint, XML, Swagger, Postman, MS Office Suite, MS Visio, MS Windows.


Business System Analyst


  • Interacted with users and stakeholders to identify business needs, evaluated solutions for business problems.
  • Conducted Joint Application Development (JAD) sessions and Requirement Workshops (RW) with Subject Matter Experts.
  • Configured Data security and Organizational hierarchy for Org salesforce implementation.
  • Customized page layouts, custom objects, fields, Dashboard, Sales, and Account.
  • Involved in Design and development of Workflows rules, triggers, validation rules and customizations with Salesforce.
  • Responsible for all the activities related to configuring Import Wizards, Data Loader.io, uploading data in CSV files into salesforce.com, checking for integrity of the data. Set up visibility securities like roles, profiles, field level securities.
  • Created and maintained Data Mapping Documents and Data Lineage Designs in MS Excel and MS Visio.
  • Designed and developed all Use Cases and UML models using MS Visio.
  • Assisted in designed Test Plans, Test Cases for Functional Testing, Load Testing and User Acceptance testing (UAT) and assisted Quality Assurance Teams in tracking the issues.
  • Provided the sophisticated user manuals and training material to the marketing team to create Product Demo videos.

Environment: AGILE Scrum, Guidewire Insurance Suit, SOA, MS project, MS office Suit, MS Project, MS Visio, Angular JS (SPA), Eclipse IDE Juno 3.8, Load Runner 11.5, Rally ALM, Apex Data Loader, Workflow Approvals.

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