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Business Analyst Resume

Madison, WI


  • Experienced Senior Business Analyst with 10+ years of proven skills in requirement gathering, interacting with developers, documenting various business processes, executing test plans, coordinating various projects contributing in Medicare in region of Healthcare IT Sectors.
  • Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum, RUP (Rational Unified Process) and Software Testing Life Cycle (STLC).
  • Experienced in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
  • Strong understanding and working knowledge of MMIS subsystems like Claims, Pre - Admission Screening, EDI, TPI.
  • Strong Knowledge and experience of EDI transactions, HIPAA, 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).
  • Extensive experience in Healthcare/Claimsadjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277).
  • Good understanding of X12, XML, EDIFACT and VDA. Deep knowledge of PPACA rules surrounding the Enrolment and Eligibility piece. Knowledge about ANSI X12 EDI standard and HIPPA compliancy mandates for ANSI X12 EDI.
  • Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management)
  • Participated in and lead the implementation of activities that support specific quality and HEDIS projects, activities, and process improvement strategies in collaboration with other departments and associates.
  • Experience with Clinical, HL7, EMR and EHR projects
  • Experience with administrating the Alaskan product line (Jira, Agile, etc.)
  • Experience with Agile Extreme Programming (XP) development and Scrum lifecycle practices, or a strong desire to learn including: pair programming, test driven development, continuous integration, iterative delivery, retrospection.
  • Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services.
  • Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
  • Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
  • Familiar with HIPAA Standards and Compliance issues, HIPAA Privacy policy, requirements gathering in compliance with HIPAA standard.
  • Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
  • Involved in testing QNXT Member, Provider, Claims Processing (with proper ICD - 9 and ICD - 10 and HCPCS/CPT codes), and Utilization Management, Contracts, and Benefits modules.
  • Expert in HIPAA Transactions testing and in-depth knowledge of HIPAA framework (Health Insurance Portability Accountability Act) rules for ANSI X12 messages 837P, 835, 276/277, 270/271, TA1 and 997 in 4010A1 Standards.
  • Facilitated one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
  • Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
  • Involved in maintaining performing GAP analysis, Requirement Analysis, Document Analysis.
  • Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
  • Proven ability to support multiple complex projects under tight deadlines, often with competing priorities


Confidential, Madison, WI

Business Analyst


  • Gather requirements and document the proposed processes to the existing system. Modules included: Claims Processing Files and HIPAA Guidelines adherence across the company.
  • Involved on HIPAA translation-based claim processing systems (claims and encounters) and other ANSI X12 EDI implementations
  • Worked with the developing team to create an advanced claim submission process for Medicare and Medicaid patients as well as EDI transactions such as: 837 (P, I, D), 835, and 276/277.
  • Involved in manual claims Adjudication process.
  • Creating, Approving and Modifying PA in both Portal and QNXT.
  • Involved in Adding Contracts to the Provider in QNXT and associating Providers in Portal while creating claims.
  • Involved in Functional, Integration, and Regression testing of the application.
  • Processed Medical claims and applied edits to the claims for testing purposes
  • Involved in Processing QNXT 837 Healthcare Claims (Institutional and Professional) in PORTAL with valid TPI.
  • Worked in utilization management module for to create and test PA.
  • Involved in uploading and processing of EDI 278, 276 claims in Portal.
  • Prepared sample EDI test sets for files like 276/77, 278,837 and followed HIPAA implementation guide in preparing them.
  • Also used BizTalk server as middle ware server to see responses for X 12 files like 835.
  • Coordinated with offshore people and updated the tasks to manager.
  • Worked with stakeholders in UAT environment to ensure Business requirements are tested properly.
  • Logged defects in Clear quest and worked with the developers to resolve any issues.
  • Conducted Regression Test for the fixes of the application
  • Used RMT for running the tasks like uploading, modifying, executing and taking logs accordingly.
  • Updated status report on weekly Basis and submitted to the team prior to weekly meeting.
  • Participated actively in conference calls, project meetings and delivered input.
  • Organized and facilitated Agile and Scrum meetings, which included Sprint Planning, Daily Scrums or Stand-ups, Sprint Check-In, Sprint Review & Retrospective.
  • Manage and administer JIRA software/Confluence/Bit Bucket add-ons, plugging, and extensions.
  • Document results of JIRA software workflows and process audits.
  • Develop guides and documentation for JIRA software features and best practices.
  • Hands-on lead for an agile team working in a continuous delivery model.
  • Plan delivery of work; demonstrate active leadership within the team and agile practices.
  • Experience in claims processing applications, claim adjudication process, claims management process, real time claims adjudication, Electronic Medical Records / Electronic Health Records (EMR/EHR)andMedicaid Management Information System (MMIS), andMedicaid Information Technology System (MITS).
  • Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
  • Enhanced applications associated with Claim Numbers so that duplicate Claim Numbers could be allowed in the system. Updated the Electronic Claims, Patient Screen and Sales Administration processes.
  • Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
  • Claim Transactions and Billing Transactions - Created flows for adequate matching of Claims. Matched Billing File andEDIClaim File records upon receipt.
  • Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
  • Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure required interactions are met during the SDLC process.
  • Involved in creating and executing test cases, test plans and test scripts for EDI 837 Claims (I & P) Transactions.
  • Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
  • Performed Data mapping to validate and customize Claims daily load into the system for processing the transactions.
  • Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors with the process of EDI inbound and outbound files
  • Created Test File to be sent to the Vendors for approval. Worked on a Paid without prejudice project for various States.
  • Testing - Developed Test Scripts using Quality Center and coordinated with developers to quickly resolve the defects associated with them.
  • Conducted JRP sessions and JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications.
  • Planned the entire Data Warehousing initiative from requirements gathering, analysis, design, identifying and analyzing the source systems, to data quality, to ETL, and to the end user data access.
  • Provided release management strategy checklists and change management techniques.
  • Presented and assisted end users for education and training about the new system.
  • Generated reports using SQL and MS Excel spreadsheets.
  • Involved in Source Data Analysis, analysis and design mappings for data extraction.

Confidential -Honolulu, HI

Business Analyst


  • Submit and gain approval of EDI encounter transactions.
  • Worked on QNXT including Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
  • Uploaded Test Cases into HP ALM Test Plan and Test Lab and monitored UAT coordinator Testers while they were testing.
  • Involved in analyzing activities for a variety of major projects including Medicare Plan part D,Coordination of Benefits, New Client Implementations, Consumer driven and regularly scheduled system upgrades.
  • Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
  • Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure required interactions are met during the SDLC process.
  • Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors with the process of EDI inbound and outbound files
  • Business Process Analysis/End User Education/Business Requirements Documentation
  • Validated System configuration, including enrollment, provider and benefits modules
  • Creation of queries and reports to assist Health Plan Operations with the analysis of data relating to claims, members and providers.
  • Utilized JIRA for issue management.
  • Execution of daily, weekly and monthly reports and processes and the creation of ad-hoc reports.
  • Broad knowledge of CCHP departmental processes, procedures and data.

Confidential, Eagan, MN

Business System Analyst


  • Review all Medicaid / Medicare agreements, changed if there is change in rates with eff dates
  • Document all provider rates and reimbursement methodologies.
  • Provide one point of contact for the UAT Coordinator testers and business unit during UAT Testing.
  • Validated configuration through various claim scenarios and quality processes.
  • Worked closely with all levels of personnel at the client site.
  • Provided ongoing support and mentoring of staff, in addition to performing periodic performance review.
  • Performed a wide range of claims testing scenarios in order to ensure proper configuration and claims payment.
  • Worked closely with other client-based testing and configuration staff.
  • Configured Providers (IPA, Group Practice and Facility), agreements for group practices, and pricing into the provider agreements
  • Involved in load and maintenance of QNXT Reference information: Claims Finance Codes, Medical Codes, and Configuration.
  • Involved in overall System updates and testing: loading and updating Fee Tables, Provider Configuration, Provider demographics, Service group configuration etc.
  • Contract Configuration - creating new contracts of all types (Facility, Physician, DME, ASC, SNF, DRUG).
  • Contract Type (Medicare, Medicaid, Commercial, etc.) and enhancing existing contracts with knowledge of various payment methods, Custom DRG, Per diem, etc.
  • Use of Term Restrictions and Restriction Groups in Contract/Benefit Modules.
  • Benefit Configuration - setting up new Benefit Plans, making changes to existing benefit plans in the all areas including co-insurance/co-pay, deductible, out of pocket maximum, accumulators.
  • Resolving Service Groups with benefit terms and addition of service groups to all Plans.
  • Analyze changes across all benefits plans (e.g.: SNF to all Plans, benefit terms, contract and contract terms) in order to configure complete solutions for Medicare (example changes in RBRVS rates) and Medicaid
  • Provided changes to configuration, to support various line of Business, were done prior to migrating to PROD.
  • Ensured correct pricing/configuration of each benefit plan and contract
  • Helped create Reports for reporting of errors and fault finding.
  • Undertook fault-finding and process improvement with technical and non-technical users and ensure that provider groups and individual providers are entered and setup in the QNXT system so that other downstream processes will function effectively.
  • Reviewed the range of approaches used to undertake key tasks such as; adding providers or configuring provider groups and then develops written guidance and training materials.
  • Participated in and lead groups in operational fault finding and remediation for providers in the QNXT application.

Confidential - Columbus, GA

Healthcare Business Analyst


  • As an active member of PDP team, interacting with developers, business users and subject matter experts (SMEs) to analyze and configure PBM Web-Portal functionality based on Business Requirement.
  • Gather and analyze requirements for Member eligibility (Group and Individual), Coordination of Benefit (COB), Billing and Payment to develop PBM (Pharmacy Benefit Management).
  • Worked on Configuration and integration of Member Enrollment, CMS, Drugs, and Plans, Pharmacy, Claims, Clinical and AR/AP (member activity) Management sections.
  • Create and Analysis of Data Transaction Reply Report (DTRR), Schedule meetings with Business team and Developers on project status.
  • Conduct JAD sessions with Business Team and Developers to discuss the Code implementation and configuration of Web Portals.
  • Performed Regression testing on both internet and intranet Web-portals to check compatibility between two code releases.
  • Create and Maintain Requirements, Test Cases and Test Plans
  • Coordinate with BSA to analyze User requirements, Current operational procedures, functional specifications and User data processing.
  • Run Batch eligibility query (BEQ) files; check Transaction Code (TC) and Transaction Reply Code (TRC) to make sure Member enrollment has been completed.
  • Perform object-oriented analysis, discuss findings with Developers to make sure both teams are on same page during the development process.
  • Attend walk through meetings for Requirements Review, Analysis and Approval of them.
  • Worked on System and Integration testing and used Mantis (Bug tracking tool) to report and monitor issues in code, Perform Manual Testing to make sure issues have been fixed.
  • Deal with CMS Member Pending Enrollment on daily basis like Low income Part (LIP)-D, Late enrollment penalty (LEP) etc.
  • PBM in corporate complete Member Enrollment and Eligibility check, Drugs Pharmacy, Plan design, Claim Adjudication and Verification, Call chain, Rx enquiry, Clinical requests handling etc.
  • Developed Traceability Matrix including BRD and FRD to track down different defects related to Member enrollment & eligibility, Claims adjudication, Clinical request from members.

Confidential, Tallahassee, FL

Business Systems Analyst


  • Performed requirements gathering and analysis, ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
  • Maintained a very close interaction between IT team, developers, Project manager to avoid any gaps in understanding or implementation of requirements.
  • Worked closely with the project team in planning, coordinating and implemented QA methodology on various phases of the application.
  • Interacted with the technical team for the claim’s transactions design.
  • Performed GAP Analysis for new functionality requirements and prioritized them based on the business needs
  • Created workflow diagrams, UML diagrams, use cases, process flow diagram, test cases and test plans.
  • Managed the Requirements (Business as well as System requirements), performed requirements analysis along with the creation of Use Case Scenarios.
  • Gathered Business/Functional Requirements from Business/R&D Users.
  • Worked with the development team to make sure that they understood the user requirements and that the system developed met those requirements.
  • Participated in developing test plans templates and guidelines to be used by the project team with detailed screen layouts with regards to various types of corporate actions.
  • Completed a thorough customer analysis and prepared a Request for proposal (RFP) document and got the shortlisted vendor document signed off. Finally, CRM (Customer Relationship Management) was decided upon by the stakeholders among shortlisted as final implementation customer
  • Involved in User Acceptance Test as needed.
  • Involved in the development of Test Plans and Test Cases and coordinated the tests with the QA team to verify implementation of new features and enhancements.
  • Created manualTest CasesinHP QC/HP ALMfor variousUser Storiesbased onReleaseandSprintPlan.
  • Worked with the Project Manager on various Project Management activities like keeping track of Project Status and Deadlines/Milestones.
  • Conducted the initial study of Health Care Management to collect customers’ information like data about existing systems at customer site, specific customer requirements.
  • Involved in Business Process Reengineering (BPR) - analyzed existing business processes and implemented new improved processes.
  • Co-authored detailed Business Requirements Document and Functional architecture and solution Specification Document.
  • Highly involved with Unit testing, System testing and Integration testing.

Confidential, Portland, OR

Business Analyst


  • Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
  • Created Use-Cases and Requirements documents to document business needs.
  • Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts and other potential users of the application.
  • Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
  • Created and maintained the Requirements Traceability Matrix (RTM).
  • Worked on Guidewire, extensively worked on Guidewire Policy center & Guidewire Claim Center
  • Used Guidewire software to track the claims of the policyholders.
  • Guidewire was specifically used by the team to implement the enhancement to expedite the claim process for unregistered users
  • Used Guidewire to upgrade the current Claim system to track the claim of the policyholders and third-party applications
  • Involved with the testing team to check the augmentations done previously using Guidewire.
  • Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
  • Maintained documents and the effect of proposed changes on the project schedule and costs.
  • Used Rational Clear Quest for bug reporting.
  • Documented the Use Cases and Activity diagram worked on COTS Integration and Application Architecture design. Created and maintained workflow plans and business process flows using MS Visio 2013.
  • Worked directly with software engineers to ensure clear communications on requirements and defect reports.
  • Designed and developed scenarios based on business requirements.
  • Developed requirements integrating E-R diagrams and designed the testing process flows.
  • Followed the RUP methodology for the entire SDLC.
  • Used the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of the Software Development Life Cycle.
  • 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.

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