SUMMARY

• Experienced Senior Business Analyst wif 10+ years of proven skills in requirement gathering, interacting wif 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 wif 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 teh Enrolment and Eligibility piece. Knowledge about ANSI X12 EDI standard and HIPPA compliancy mandates for ANSI X12 EDI.
• Served as a liaison between teh internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management)
• Participated in and lead teh implementation of activities that support specific quality and HEDIS projects, activities, and process improvement strategies in collaboration wif other departments and associates.
• Experience wif Clinical, HL7, EMR and EHR projects
• Experience wif administrating teh Alaskan product line (Jira, Agile, etc.)
• Experience wif 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 wif teh Business Requirements.
• Familiar wif HIPAA Standards and Compliance issues, HIPAA Privacy policy, requirements gathering in compliance wif HIPAA standard.
• Proven ability to analyze complex problems, identify risks and develop TEMPeffective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Involved in testing QNXT Member, Provider, Claims Processing (wif 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 wif business owners to identify, prioritize and document business requirements.
• Proven ability to support multiple complex projects under tight deadlines, often wif competing priorities

PROFESSIONAL EXPERIENCE

Confidential, Madison, WI

Business Analyst

Responsibilities:

• Gather requirements and document teh proposed processes to teh existing system. Modules included: Claims Processing Files and HIPAA Guidelines adherence across teh company.
• Involved on HIPAA translation-based claim processing systems (claims and encounters) and other ANSI X12 EDI implementations
• Worked wif teh 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 teh Provider in QNXT and associating Providers in Portal while creating claims.
• Involved in Functional, Integration, and Regression testing of teh application.
• Processed Medical claims and applied edits to teh claims for testing purposes
• Involved in Processing QNXT 837 Healthcare Claims (Institutional and Professional) in PORTAL wif 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 wif offshore people and updated teh tasks to manager.
• Worked wif stakeholders in UAT environment to ensure Business requirements are tested properly.
• Logged defects in Clear quest and worked wif teh developers to resolve any issues.
• Conducted Regression Test for teh fixes of teh application
• Used RMT for running teh tasks like uploading, modifying, executing and taking logs accordingly.
• Updated status report on weekly Basis and submitted to teh 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 wifin teh 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 wif Claim Numbers so that duplicate Claim Numbers could be allowed in teh system. Updated teh 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 teh 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 teh system for processing teh transactions.
• Validated Inbound and outbound 837 transactions, including but not limited to teh loading and correcting any errors wif teh process of EDI inbound and outbound files
• Created Test File to be sent to teh Vendors for approval. Worked on a Paid wifout prejudice project for various States.
• Testing - Developed Test Scripts using Quality Center and coordinated wif developers to quickly resolve teh defects associated wif them.
• Conducted JRP sessions and JAD sessions wif teh management, users and other stakeholders for open and pending issues to develop specifications.
• Planned teh entire Data Warehousing initiative from requirements gathering, analysis, design, identifying and analyzing teh source systems, to data quality, to ETL, and to teh end user data access.
• Provided release management strategy checklists and change management techniques.
• Presented and assisted end users for education and training about teh 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

Responsibilities:

• 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 teh SDLC process.
• Validated Inbound and outbound 837 transactions, including but not limited to teh loading and correcting any errors wif teh 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 wif teh analysis of data relating to claims, members and providers.
• Utilized JIRA for issue management.
• Execution of daily, weekly and monthly reports and processes and teh creation of ad-hoc reports.
• Broad knowledge of CCHP departmental processes, procedures and data.

Confidential, Eagan, MN

Business System Analyst

Responsibilities:

• Review all Medicaid / Medicare agreements, changed if there is change in rates wif eff dates
• Document all provider rates and reimbursement methodologies.
• Provide one point of contact for teh UAT Coordinator testers and business unit during UAT Testing.
• Validated configuration through various claim scenarios and quality processes.
• Worked closely wif all levels of personnel at teh 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 wif other client-based testing and configuration staff.
• Configured Providers (IPA, Group Practice and Facility), agreements for group practices, and pricing into teh 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 wif 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 teh all areas including co-insurance/co-pay, deductible, out of pocket maximum, accumulators.
• Resolving Service Groups wif 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 wif technical and non-technical users and ensure that provider groups and individual providers are entered and setup in teh QNXT system so that other downstream processes will function TEMPeffectively.
• Reviewed teh range of approaches used to undertake key tasks such as; adding providers or configuring provider groups and tan develops written guidance and training materials.
• Participated in and lead groups in operational fault finding and remediation for providers in teh QNXT application.

Confidential - Columbus, GA

Healthcare Business Analyst

Responsibilities:

• As an active member of PDP team, interacting wif 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 wif Business team and Developers on project status.
• Conduct JAD sessions wif Business Team and Developers to discuss teh 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 wif 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 wif Developers to make sure both teams are on same page during teh 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 wif 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

Responsibilities:

• 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 wif teh project team in planning, coordinating and implemented QA methodology on various phases of teh application.
• Interacted wif teh technical team for teh claim’s transactions design.
• Performed GAP Analysis for new functionality requirements and prioritized them based on teh business needs
• Created workflow diagrams, UML diagrams, use cases, process flow diagram, test cases and test plans.
• Managed teh Requirements (Business as well as System requirements), performed requirements analysis along wif teh creation of Use Case Scenarios.
• Gathered Business/Functional Requirements from Business/R&D Users.
• Worked wif teh development team to make sure that they understood teh user requirements and that teh system developed met those requirements.
• Participated in developing test plans templates and guidelines to be used by teh project team wif detailed screen layouts wif regards to various types of corporate actions.
• Completed a thorough customer analysis and prepared a Request for proposal (RFP) document and got teh shortlisted vendor document signed off. Finally, CRM (Customer Relationship Management) was decided upon by teh stakeholders among shortlisted as final implementation customer
• Involved in User Acceptance Test as needed.
• Involved in teh development of Test Plans and Test Cases and coordinated teh tests wif teh QA team to verify implementation of new features and enhancements.
• Created manualTest CasesinHP QC/HP ALMfor variousUser Storiesbased onReleaseandSprintPlan.
• Worked wif teh Project Manager on various Project Management activities like keeping track of Project Status and Deadlines/Milestones.
• Conducted teh 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 wif Unit testing, System testing and Integration testing.

Confidential, Portland, OR

Business Analyst

Responsibilities:

• 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 wif loan analysts, credit analysts and other potential users of teh application.
• Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in teh same.
• Created and maintained teh Requirements Traceability Matrix (RTM).
• Worked on Guidewire, extensively worked on Guidewire Policy center & Guidewire Claim Center
• Used Guidewire software to track teh claims of teh policyholders.
• Guidewire was specifically used by teh team to implement teh enhancement to expedite teh claim process for unregistered users
• Used Guidewire to upgrade teh current Claim system to track teh claim of teh policyholders and third-party applications
• Involved wif teh testing team to check teh augmentations done previously using Guidewire.
• Ensured Use-Cases were consistent and covered all aspects of teh Requirements document.
• Maintained documents and teh TEMPeffect of proposed changes on teh project schedule and costs.
• Used Rational Clear Quest for bug reporting.
• Documented teh 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 wif 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 teh testing process flows.
• Followed teh RUP methodology for teh entire SDLC.
• Used teh guidelines and artifacts of teh Rational Unified Process (RUP) to strategize teh implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of teh Software Development Life Cycle.
• Interacting wif other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated teh scripts to make sure they have been executed correctly and meets teh scenario description.