SUMMARY

• 6 plus years as a Business/Systems Analyst within the Health Care domain.
• Expert knowledge in Business Process Flow, Data Analysis and Data Mapping.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Expert in developing Business, System and Functional Requirements, Design Documents, working with requirements traceability matrix.
• Strong knowledge of Software Development Life Cycle (SDLC - Feasibility Requirements Analysis, Design, Construction, Testing, Implementation, Support) and Rational Unified Process (RUP) and UML methodology.
• Proficient in rational tools including rational rose and rational requisite pro.
• Proficient in creating Business Requirement Documents (BRD), Functional Requirement Specification (FRS) document, User Requirement Specifications (URS) document.
• In depth knowledge HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
• Knowledge of healthcare standard Health Level Seven (HL7).
• Expertise in developing automation scripts in BDD format usingcucumberand proficient in writing cucumber scenarios inGherkin format.
• Experienced in preparing Business Process Re-engineering Models
• Expertise in the EPIC Medical software application (EMR, EHR) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• In depth knowledge of SDLC and implementation of the Rational Unified Process (RUP) in all four phases of a project: Inception, Elaboration, Construction and Transition.
• Performing UAT and exposure to User Certification Testing (UCT) and Operational Readiness Testing (ORT).
• Proficient in developing and executing Test Plans, SQL and PL/SQL queries, performing functional, usability testing and ensuring that the software meets the system requirements.
• Extensive Data Warehousing experience using Informatica as ETL tool on various data bases like Oracle, SQL Server, Teradata, MS Access.
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Experience in Change Management Process (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Excellent skills in Project and Performance Management to support Strategic Planning, Goal Setting, Strengthen Accountability, Enhance Decision Making, and Improve Customer Service.

TECHNICAL SKILLS

Business Modeling Tools: Visual Paradigm, MS Visio, PowerPoint, Rational Rose

Requirements Gathering Tools: Rational RequisitePro, MS Word, MS Excel

Microsoft Tools: MS Office, MS Visio, MS Project

SDLC Methodologies: RUP, Prototyping, RAD,Agile, Waterfall

Testing Tools: Mercury Test Director

Database: MS Access, Oracle 9i, MySQL

Operating Systems: Windows 7/2000/XP, Vista, DOS

Programming Languages: PL/SQL,VB.Net, QBasic, HTML,PHP, ASP.Net

Defect Management Tools: Mercury Test Director, Rational ClearQuest

PROFESSIONAL EXPERIENCE

Confidential, Springfield, IL

Sr. Business Systems Analyst

RESPONSIBILITIES:

• Gathered requirements from stakeholders for provider management and member management.
• Identified and validated business rules and data elements.
• Worked in uploading encounter data, and eligibility submissions from providers.
• Worked in EDI X12 transactions 837P,837I&837D for encounters adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Worked on developing Conceptual Data Model & Logical Data Model in alignment with MITA Information Architecture.
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Business Process Model (BPM) tool.
• Modeled the ‘As-Is’ process flow and the ‘To-Be’ process flow and analyzed the gap and developed the action steps to fill the gaps.
• Maintained a bi-weekly status report for the requirements team and incorporated the same to the PMOstatus reports send to CMS.
• Created and maintained operation dashboard system to track health of various metrics usingTableauData Visualization Software.
• Prepared the data mapping document which captures the data source, filter, and target to facilitate the ETL team to feed the data into data warehouse and integrate the process. Responsible for data migration (ETL development), document data manipulation using excel.
• Wrote impact analysis for State Medicaid programs to implement T-MSIS reporting requirements to CMS
• Wrote Business Requirements for the MMIS System, authored Business Test Requirements, and reviewed/upgraded technical design specifications. 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. Conducted Impact analysis when there is any change in the requirements and updated the Business Requirements Documents.
• Worked on Provider inquiry about the status of claims. This involved checking the MMIS claims subsystem to see the status of claims sent and informing the providers if the claims have been suspended / denied or paid.
• Extensively usedMMISClaims Processing System for adjudication and pricing of claims.
• Provided inquiry about the status of Remittance Vouchers (RVs). This involved checking the MMIS provider subsystem and checked the setup of their Remit Data.
• Worked extensively in Encounter processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, and Medicaid.
• Experience with Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 837 and proprietary format files and Reports development.
• Worked with Jira for defect management.
• Involved in claims encounter processing system. Managed and developed EDI specifications, gap analysis, and applications structures for data feeds and mappings for integration between various systems, including XML, to follow ICD 10 Code set, including 270 Eligibility Benefit Inquiry, 271 Eligibility Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 700 Attachment Request, 701 Attachment Response, 810 Invoice, 820 Payment Order Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice, 837 Claims and Encounter, and 999 File Transmission Acknowledgement, to meet and exceed HIPAA requirements.
• Involved in testing of claims processing for multiple MCOs through Medicaid Management Information System (MMIS).
• Supported MCOs EDI Snip Level 1 validation for any failure support.
• Supported MCOs for Missing/ Rejected 999’s and how to resolve them.
• Worked with multiple MCOs and provided guidance for their Missing Encounter claims and trackback..
• Worked with BTS (Bureau of technical Support) to request PIR/ PRR/CR for identified MMIS Issue.
• Involved in reviewing and giving error analysis support for Encounter claims.
• Conducted weekly meetings with Individual MCO teams to elucidate our requirements.
• Worked with MCOs and ensured the State is collecting all necessary Hedis administrative data and all data is collected accurately and timely during Hedis hybrid review..
• Collected medical records for Risk Adjustment, HEDIS and gaps of care to assist in organizing data to be accurately entered into the database. Also worked on risk adjustment audit requests from OIG (Office of Inspector General) at HFS Confidential .
• Involved in Requesting and validating test files for the new programs for UAT testing an provided support in reconciliation process of the test files.
• I have Created and uploaded Requirements and Test Cases on HP ALM
• I have worked on billing and payments in the provider module in Claim Test Pro of MMIS. Test Case design and Test execution using HP ALM
• Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM (Change Health) and encounters adjudication is done through MMIS system.
• Developed UAT test cases associated with the functional requirements. Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
• Examined the system design deliverables & validated it against the Request for Proposal (RFP).

Environment: Windows7 professional, MS Office suite, MS Project, ReqPro, UNIX/Oracle Platform, Bi XML, SQL, Tableau, Cognos, Jira, Tera Data SQL, Agile, MS Visio, RUP 2011, Rational Rose, Rational Clear Quest, Enterprise Architect, Mainframe MMIS system, Rational Requisite Pro.

Confidential, Orange County, CA

Sr. Business Systems Analyst

RESPONSIBILITIES:

• Utilized SDLC Methodology to configure and develop process, standards and procedures
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business workflows & task analysis, and determine whether any current or proposed systems are impacted by the new development efforts
• Designed Test Plans, Scripts after analyzing various scenarios/requirements & performed defect tracking using Test Director & Clear Quest.
• Involved in analyzing the encounter claims on basis of Primary and Secondary Payers and performed Medicare subsidy eligibility check for employee group plans.
• Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed (837P, 835, 834)
• Documented and estimated the Cost/Benefit of enhancement requests using a predefined estimation worksheet for missing functionality in a basic way to forward to business analysts for prioritization as enhancements to systems for development of new data sources as exports from source systems into business intelligence tools (Tableau).
• Tested encounter claims adjudication and group and enrollment for New Medicare advantage members.
• Worked on receiving Encounter files from their PBM (Pharmacy Benefit Manager), verifying the data content by transactional analysis.
• Performed in production support role by analyzing and remediating data quality issues reported by business users of the data warehouses. Ran SQL queries and examined ETL specification documents to correct data.
• Analysis and Design of the Erisco FACETS data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan.
• Performed Data modeling by creating logical and Physical models of the database system.
• Responsible for writing the Test Cases and Test Scenarios based on the Functional Specification and technical Specification and documented in Mercury Quality Center.
• Performed User Acceptance testing & End to End testing in interaction with Offshore QA/dev teams for various system releases & pushed them to production
• Expertise in Bug tracking and reporting using Jira, ALM Quality Center and Rational Clear Quest. And experience of Bug life cycle system
• I have prepared test matrices based through defect status in Quality Center/ALM.
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Always maintained excellent problem-solving and communication skills; and effectively listened, negotiated, debated, discussed, brainstormed, communicated, and collaborated with a variety of individuals and groups

Environment: Rational Suite (Rose, Requisite Pro), Rational Unified Process (RUP), Windows 7 Professional, UML, UNIX, MS-Project, SQL Teradata, MS-Office Suite, Casewise Corporate Modeller,WinRunner, Test Director, Mainframe MMIS Syatem

Confidential, Columbia, SC

Sr. Business Systems Analyst

RESPONSIBILITIES:

• Performed requirements gathering from the business users of the system while adhering to SDLC (Software Development Life Cycle) industry best practices.
• Developed excel models to derive the amortization schedule for Whole loan products and Mortgage Backed Securities
• Interacted with Software development team and Business users as a liaison in helping developers to understand the business requirements thereby ensuring the proposed applications comply with the business specifications.
• Assisted in the automation of the mortgage portal with the Loan IQ system for the conditional approval
• Analysed information and requirements and documented them. Reviewed the Business Requirement document and detailed the Systems Requirement document.
• Build a data model which integrates Loan IQ Application to centralized Data Warehouse with PeopleSoft integration. Worked in the process of upgrading the PeopleSoft version from 8.9 to 9.1.
• Designed different document templates to gather Business Requirements, Change Requests, gap analysis and UAT.
• Implemented the entire Rational Unified Process (RUP) methodology of application development with its various workflows and activities.
• Prepared an ROI analysis report after evaluating the COTS product of the multiple business lines.
• Analysed the system to be implemented for production to ensure that it handles incomplete and accurate data and performs default method of calculations for various mortgage products like Mortgage Backed Securities, and Asset Backed Securities.
• Met with different business users to determine user requirements and goals.
• Developed and Documented timelines for Project Delivery, and managed Projects and Resources to successful completion.
• Conducted presentations to make users understand about the processes.
• Interacted with the business and technical team to create front-end and back-end FSD’s and communicated these to the stakeholders while co-coordinating approvals.
• Prepared project plan and defined different milestones.
• Involved in validating XML files/Web Services against SOAP Protocol.
• Employed a variety of technical tools to design applications for the Loan IQ system including: SQL, DB2, QMF, JCL, FTP, GDG, MS Excel, VB Macro, and PLI.
• Discussed different functional requirements and defined high level design and Use Cases.
• Developed process flow diagrams (flow charts) using MS Visio in an effort to identify and analyse process flows in the Safe Deposit Box system.
• Used MS Excel and MS Word to create a field-to-field data map that was used as a main specification document for the conversion program.
• Developed traceability matrix for maintaining/updating system requirements using MS Excel.
• Prioritized outstanding defects and system problems, ensuring accuracy and deadlines were met. Identified and participated in resolution of business system issues.
• Lead Validation/Verification, SIT (System Integration Testing), mock conversion on the system to ensure data accuracy and Bank’s business needs.
• Wrote User Acceptance Test Plan based on business users requirements and reviewed Test Plan templates.
• Delivered and maintained extensive documentation for future extendibility of the system

Environment: Rational Suite (Rose, Requisite Pro), Rational Unified Process (RUP), Windows 7 Professional, Oracle, PL/SQL, MS-Project, MS-Office Suite, ALM Quality Center11.0, MS Visio, MS Word, MS Excel, PeopleSoft 9.2, Agile/Scrum, XML, HTML