SUMMARY

• More than 8+ years of proactive IT experience working as Business/System Analyst in Healthcare industry with expertise in Healthcare Systems ITS, Health insurance plans Indemnity plans, Managed Care plans HMO, PPO POS, Government Sponsored Programs Medicare, Medigap, MMIS, FEP SHBP Consumer Driven Health plans CDHP. Medicare Part A, B, C, D and Medicaid systems
• Experienced and in - depth knowledge of all phases of System Development Life Cycle (SDLC) methodologies such as Waterfall, Agile-Scrum, and Waterfall-Scrum Hybrid.
• Skilled in creating operational workflows, data diagrams, and other industry standard documents to represent client's business processes and other needs.
• Experience with TriZetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Experienced in developing Work Flows and Activities, Rule based Business Process Management using Pega Rules Process Commander PRPC, Decision tables, Decision maps, Declarative expressions, Constraints, and Indexes
• Extensive experience in Unified Modelling Language diagrams (like Use Case, Activity, Sequence, data flow) and charts (like velocity, burn down charts) respectively using Rational Rose, TFS, JIRA and MS Visio.
• Widespread knowledge of EHR/EMRs Electronic Medical Records, HL7 and its Patient Protection and Affordable Care Act PPACA.
• Worked with AWS Cloud platform and its features which includes EC2, VPC, RDS, EBS, S3, CloudWatch, Cloud Trail, CloudFormation and Autoscaling etc.
• Experience in DCO tools like Application Profiler, Sizing and Estimation, Application Document Wizard, Requirement Document Rules, Use Case Requirement Rules in Pega.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Good knowledge and extensively used RDBM, SQL, along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Working knowledge of MMIS (Medicaid Management Information System), HIX (Health Insurance Exchange), EMR (Electronic Medical Record), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA), Emergency Medical Treatment and Active Labor Act (EMTALA).
• Familiarity with current technology and industry standards such as APIs, FHIR, JSON etc.
• Experience in Database design and development using Oracle 10g, and Oracle PL/SQL. Experience in Database Performance tuning and SQL query optimization.
• Experienced with HIX Health insurance Exchange, PPACA Patient Protection and Affordable Care Act, Plan Management, Eligibility and Enrolment process, SHOP Small Business Health Options Program as well as Financial Management.
• Used AWS command line client and management console to interact with AWS resources and APIs.
• Working knowledge of Health Insurance Programs (Medicaid, Medicare Part A, Part B, Part C, Part D) and Managed Care Programs (HMO, PPO, POS), with expertise in paper claim forms (CMS 1500, UB 04).
• Experience in creating Test Plans, Test Scenarios and Test cases and documenting project processes and procedures.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations
• Excellent ability and capability to interact with customers. Self-motivated with effective communication skills and strong background in multiple tasking. Ensure that value is delivered by deriving the need of the client

PROFESSIONAL EXPERIENCE

Sr. Business System Analyst

Confidential -Detroit, MI

Responsibilities:

• Functioned as the liaison between the line of business and the technical teams throughout the project life cycle.
• Conducted Joint Requirements Planning (JRP) sessions with the Subject Matter Experts (SME) and the key stakeholders to understand business requirements and the functionalities in detail.
• Demonstrated understanding of best practices for the architecture, processing, analyzing, modeling, and managing of healthcare data, using Infrastructure as a Service (IaaS) for cloud migration
• Assisted with the implementation and ongoing support of the Health Insurance Exchange HIX environments.
• Extensively working with HL7 messages like ADT, ORM and ORU during while integrating helix with the existing applications.
• Collaborated with UI/UX, API and System teams to support development initiatives.
• Proficient in all aspects of QNXT configuration including eligibility and enrollment, provider reimbursement and network management, referral and authorizations, claims processing, and premium billing and accounting.
• Provided major contribution in the implementation of EDW Incremental pull and load that constitutes different modules like claims, providers, members, products for different source systems.
• Developed User Accepting Testing (UAT) plans and test cases based on the business requirements.
• Used PEGA Application Profiler to capture requirements and objectives into smart BPM and Document Wizard to automate creation and maintenance of documentation.
• Involved in designing and implementing service-oriented architectures (SOA) suitable for secure, reliable, and high-performance system. Created several API/web services as per business needs.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Conducted GAP analysis for identifying improvement areas from on premise data center to the Amazon Redshift.
• Worked on the screenshot and prototype development for the various online screens meant for the EHR project.
• Providing functional support for HR, Payroll, MSS applications and their interface.
• Used Amazon IAM to grant fine-grained access to AWS resources to users. Also, managed roles including permissions of users to AWS account through IAM.
• Involved in developing and executing SQL queries on claim records to validate reporting.
• Analyzed the risks involved by conducting SWOT and Cost-Benefit Analysis in Microsoft Office Environment.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277, 835, 834 EDI transactions.
• Involved in developing training program and material for new hires and existing configuration team members to increase QNXT knowledge base and facilitate cross training within configuration department.
• Facilitated the User Acceptance Testing (UAT) with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
• Maintained Gitlab repositories, JIRA bug tracking system. Created custom JIRA workflows.
• Involved in creating Unified Modeling Language (UML) diagrams including Activity Diagrams, Entity relationship diagrams and Use Case Diagrams.
• Loading of data into the EDW for direct vendors, members, eligibility, claims, symmetry segmentation, stratification/identification.
• Collaborated with Systems Architect in constructing the Architecture Diagram depicting the data migration from On-premise servers to Amazon Redshift data warehouse.
• Involved in developing solutions to fix the production issues in Oracle PL/SQL code, and interfaces permanently.
• Involved in creating Oracle PL/SQL stored procedures, function, packages, Cursor and Triggers.
• Monitored the installation progress of AWS Direct Connect to establish connection on premise to Amazon VPC.
• Well versed with EPIC, EMR systems, EPIC bridges, EHRs, Mirth and Production support processing problems by being one of the chief sources and providing alternative solutions using best practice models and principles.
• Extensively involved in performing Data Mapping by querying databases and performing Data Modelling in the Migration to Amazon Redshift data warehouse by modelling transformations in AWS Glue and Data Reconciliation
• Being able to adapt and work efficiently in an agile environment where the cumulative Standard Operative Procedure (CSOP) and Policy directives and decision Matrix documents were in process and unstable during the initial phase of the project.
• Maintained Kanban boards in JIRA, involved in creating Static Prototypes using HTML for an overview of the Graphical User Interface.
• Tested the requests and responses provided by the Restful Web Services using Postman plugin for google chrome and standardized them to the format required by the application.
• Collaborated with the Quality Assurance team to ensure adequate testing of software both before and after completion, maintained quality procedures, and ensured that appropriate documentation is in place.

Business System Analyst

Confidential -Greenville, NC

Responsibilities:

• Responsible for proactively identifying opportunities for improvement throughout the business which could include working with department management to create a business case detailing the cost/benefit of the improvement.
• Designed and documented REST/HTTP, SOAP APIs, including JSON data formats and API versioning strategy.
• 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.
• Identify areas of improvement within QNXT and write and submit PDRs to TriZetto.
• Facilitated and conducted JAD sessions with SMEs of all sources and warehouses to help them understand the EDW requirements, identify the GAPs between warehouses and EDW, and identify the alternatives.
• Involved in creating role-based matrix, decision tables when required as per the requirements through the project.
• Worked on HCM setup for company information, location, department, salary grades, job codes, benefit programs, plan types, pay groups and other payroll related issues.
• Performed extensive testing on API for ensuring accuracy of backend services.
• Involved in implementing systems that are highly available, scalable and self - healing on the AWS platform.
• 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 Pega Business Process Management (BPM) tool.
• Excellent knowledge and enacting of HIPAA (Health Insurance Portability and Accountability Act) transaction sets such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 835 (payment or remittance advice).
• Assisted other streams within the programmed in planning test cases and knowledge transfer to enable effective testing Rest API using Robot Framework and SOAP UI.
• Drafted and maintained software/business requirement documents in order to outline REST API project needs, assumptions, constraints and milestones.
• Identify and Review the HIX Work track 12 reports and compare with the Contract Reporting section.
• Successfully interpreted data to draw conclusions for managerial action and strategy.
• Optimized data collection procedures and generated reports on a weekly, monthly, and quarterly basis.
• Experienced with various database objects to write SQL queries on multiple databases like MS SQL Server, MS Access and Oracle databases.
• Analyze current configuration team SLA service level agreement and recommend more standard SLA across team members based on QNXT knowledge levels.
• Worked with HIPPA EDI files for data validation and created Data mapping and ETL process requirements for loading data into the EDW.
• Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them.
• Involved in extraction, transformation and loading of data using AWS Glue from identified data sources to S3 bucket and ultimately to Amazon Redshift.
• Worked on Health Insurance exchanges HIX and analyzed the data and worked with EDI NCPDP considerations and implemented HIPAA regulations.
• Involved in creation of search reports using List view and Summary view rules of PEGA PRPC.
• Verified the data extracted and record counts in the database with SQL Queries using AWS Athena.
• Analyzed massive and highly complex data sets, performing ad-hoc analysis and data manipulation.
• Collaborate with both technical and business stakeholders to understand reporting and data requirements based on customer and internal needs.
• Conducted Walkthroughs and Meetings involving leads from Development, QA, Database and Technical Support teams to validate the Budget planning for Amazon services.
• Responsible for identification and analysis of errors/inconsistencies in the data and provides timely resolutions.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence).
• Worked on payer plan sponsor and the EDI transactions like 837
• Provide ad-hoc and structured reporting document to partners and stakeholders.
• Was involved in maintaining dashboards, reports, visualizations, and alerts that concerned business decisions.
• Involved in creating documents like Root-Cause, Cost-Benefit, SWOT and ROI with excellent track record as a JAD facilitator and knowledge of all the best practices for requirements gathering.
• Prepared data analysis, writing data mapping documents, data transformation rules and maintained data dictionary for business intelligence and data warehouse applications.
• Single point of contact between business users, development teams and QA teams for sign-offs and finalization of requirements.
• Involved in developing strategies with Quality Assurance group to implement Test scripts in HP/Mercury Test Director for stress testing and UAT (User Acceptance Testing)
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• 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.
• Involved in creating sample mappings for the conversion of EDI x12 transactions code sets.
• Assisted clients in resolving billing issues for Medicare, Medicaid, and private insurance.
• Used complex SQL queries to analyze the data pattern to accommodate the various business scenarios.

Business System Analyst

Confidential -Santa Fe, NM

Responsibilities:

• Collected the EDI files from testers and send it to the suppliers after a high-level validation of the 850 and 844 EDI files.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Gathered high-level requirement for all the external projects in a release.
• Performed the requirement analysis, impact analysis and documented the requirements.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Utilized expertise in Content Management Systems and coding to customize Confluence Collaboration server via plugin architecture using available language APIs including Python and Java on Ubuntu and Debian based development environments.
• Created new EC2 instance in AWS, allocate volumes and giving Provisionals using IAM
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language (PL/SQL).
• Work closely with team leads in process of standardizing job parameters, job flows, audit process and rollback strategies that hold major attention for the successful implementation of EDW Incremental.
• 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.
• Provided business and mapping expertise during a transition of the EDI applications from the GXS Application Integrator (AI) to GIS.
• Involved in developing, executing and managing User Acceptance Testing (UAT), Quality Assurance (QA) in reviewing Test Procedures and Test cases, reviewing and maintaining Test script both manually and Automated.
• Did GAP analysis by comparing the past HIX reports with present Contractual Reports to create the Future Reports.
• Helped lead the transition of Requirements Management in the Business Analyst Team to the agile methodology by creating and managing user stories and Requirements Traceability Matrices in the JIRA toolset.
• Exposed to using ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both Inpatients and out patients.
• Migrated existing application into micro services architecture using Rest APIs, spring boot.
• Developing a single application to process data from multiple integration points, convert the data for reporting purposes and feed data into mainframe system to be compliant to reporting requirements.
• Performed Analysis on Data mapping between different data models.
• Provide ad-hoc and structured reporting document to partners and stakeholders.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Was involved in maintaining dashboards, reports, visualizations, and alerts that concerned business decisions.
• Followed Agile (Scrum) SDLC methodology software development.
• Performed Backend testing by using PL/SQL queries to test the integrity of the application.
• Created data mappings to transform the data according to business rules.
• Involved in developing Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
• Participated in decision around data warehouse architecture and more specifically data models and database design and code complex programs, database scripts, and ETL packages that meet data flow.
• Prepared Business Requirement Documents BRD's after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records EMR and Electronic Health Records EHR software.
• Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.
• Prepared documents for the wireframe and prepared a data dictionary for the same
• Managed testing for various functionalities using Quality Center tools.
• Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.
• Modified and translated segments of HL7 messages to properly send to EPIC.
• Analyzed and documented MMIS Claims business rules, edit rules, audit rules, to create and process unit and string test cases to verify and validate updated programs.
• Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.

Business Analyst

Confidential -Rochester, MN

Responsibilities:

• Performed extensive GAP analysis by identifying AS-IS and TO-BE process models and process flows.
• Identified the business users who will use the new application. Summarized the primary job responsibility for each user. Also identified client business needs, problems, and desired outcomes and established a common understanding of the business problems and possible solutions.
• Involved in conducting Functionality testing, Integration testing, Regression testing and User Acceptance testing (UAT). Provided analysis and insight to QA Team in defects and bugs tracking
• Responsible for eliciting, analyzing, document, business requirements, functional and non-functional specifications based on DCO sessions with business unit stakeholders and technical team members, SMEs.
• Worked with System Architects, and other project members collaboratively and iteratively to create the content in the artifacts like Application Profile, Application Specifications, Application Requirements.
• Used Agile Workbench to directly capture user stories and used JIRA for issue tracking and generated reports to analyze the performance of the project/team.
• Involved in creating requirements that comply with HIPAA, HL7, and ANSI X12 format regulations to protect the privacy of the employee insured under any policy.
• Assisted Product Owner in define Acceptance Criteria for User Stories, DOD, DOR.
• Involved in creation of Mock-Ups and Wireframes of user interface using Pega's UI Designer for client verification.
• Performing business analysis, software validation and testing for client/server, multi-tier and web-based applications for EMR and commercial business for managed healthcare plans and Industries.
• Configured payroll schema, wage types and remuneration statements.
• Involved in designing, documenting and determined n-tier architecture for the claim processing system.
• Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 to identify key data objects.
• Basic understanding of Healthcare Jargons such as Health Insurance Exchange HIX.
• Used Connect SQL rules to run SQL statements like joins to verify the authenticity of the data.
• Involved in designing an Objected Oriented Security model for different Access Groups and assigned different roles to the Users.
• Defined the Correspondence and Notification needs of the system and identified the triggers for the correspondence.
• Assisted QA team with Test Planning, Writing the test cased and Test Scenarios, Defect Tracking and Test Results.
• Involved in developing, executing and managing User Acceptance Testing (UAT).

Business Analyst

Confidential -Philadelphia, PA

Responsibilities:

• Attend all weekly and biweekly Responsive PDP Page Redesign business as well as IT meetings with the different stakeholders.
• Provided status update reports on requirement gathering process related to Responsive PDP Page Redesign.
• To understand, gather, detail and documented business as well as functional requirements related to Responsive PDP Page Redesign.
• Involved in preparing Design Documents.
• Involved in the process of integration and installation of new releases.
• Provided database support by coding utilities.
• Identified and gathered test data needed to support the testing effort.
• Held daily scrum meeting with the Project team and change management team to discuss the requirement updates, change requests, tasks and assign/re-assign man hours on a daily basis.
• Assisted in payroll preparation by providing relevant data (absences, bonus, leaves, etc.)
• Maintained application security by monitoring compliance to standards.
• Involved in performing validations by using Restful Web Services with JAX-RS.
• To prepare BRD (Business Requirements Document), FRD (Functional Requirements Document), WSRD (Web Service requirements document), and RTM (Requirements Traceability Matrix) for the Responsive PDP Page Redesign.
• Defined User roles, Authorization, and Tasks for the newly build Share Point Database management system.
• Prepared Use cases and process flows for the newly build Share point system.