PROFESSIONAL SUMMARY:

• 5+ years of Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollment and eligibility processes.
• Good functional knowledge of HIPAA regulations, ANSI X12, 4010A and 5010 standards& working knowledge of HL-7 message standards, support and maintenance.
• Complete knowledge of registration, scheduling and billing processes for Revenue Cycle and Patient flow.
• Excellent knowledge of E-Commerce, healthcare IT along with HIPAA regulations, EDI transaction Code Sets, and CMS regulations.
• Firm ability to research, analyze and translate complex business and technical information to stakeholders, SMEs, and developers at all levels of the organization. Also, in Defining, Gathering, Documenting, and Managing requirements to identify the real business need of the client company.
• Excellent communication, interpersonal consulting and facilitation skills.
• Working expertise in Software Development Life cycle (SDLC), Project Life cycle, Business Process Modeling (BPM), Software Development Methodologies including Rational Unified Process (RUP), Waterfall, Spiral, and Agile with SCRUM process
• Organize in Joint Application Development (JAD) and Rapid Application Development (RAD) sessions with business/end users, expert team and technical team.
• Significant Testing Experience in ASC X12 EDI for HIPAA and electronic healthcare transactions such as 270/271, 274, 276/277, 278, 820, 834, 835, 837 for Version 5010.
• Developed use case diagrams, sequence diagrams, state diagrams and activity diagrams, business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML).
• Experience in producing documents like Business Requirements Documents (BRD), Functional Requirement Documents (FRD), Software Requirement Specifications (SRS), Creating Request for Proposals (RFP), creating Requirements Traceability Matrix (RTM)
• Experience in creating Prototypes and Wire frames and documenting them using MS Visio and Enterprise Architect
• Involved in all phases of Testing life cycles including integration testing, User Acceptance testing (UAT) Functional testing/Black Box Testing, Regression testing, GUI testing, and performance testing.
• Hands on experience with Object Oriented Analysis and Design (OOAD); work side by side with technical managers; senior design engineers/ analysts; used UML extensively with emphasis on Use Case diagrams, state diagrams, sequence diagrams, activity diagrams and collaboration diagrams using Rational Rose and MS-Visio; solid hand-on experience working with MS Excel, writing very complex Excel macros to pull data in Data Mining and Data Warehousing environment; help in designing the ETL processes.
• Excellent verbal and written communication skills with interpersonal and analytical skills
• Demonstrated ability to adapt into new environments, learn new skills and participate/lead teams.
• Acquainted with SQL, Quality Center, Quick Test Pro, Win Runner and load Runner.
• Gathering business requirements for ICD 10 Groupings/ classes pertaining to maintenance process, ICD 10 business rules remediation process, Medical Claims Processing System (MCPS)
• Creative and aggressive self-starter and a versatile team player with excellent analytical, problem-solving capability for collecting clear and detailed Business Requirements and Functional Specifications.
• Team player, hardworking, highly self-motivated, fast-learner and goal-oriented individual committed in pursuing a long-term career in Information and Communication Technology.
• Strong analytical skills, resourceful problem solver with ability to work under pressure
• Experience in working with cross-functional/ cross-cultural groups.

TECHNICAL SKILLS:

Methodologies: Agile, Waterfall, RUP, UML, SDLC, Scrum, RUP, V-shape modelling

Change Management Tools: Rational Clear Quest, Rational Clear Case

Business Modelling & Versioning Tools: MS Visio, Visual Paradigm, Rational Rose; Rational Requisite Pro, Rational Clear Case

MS Office: MS Project, MS Word, MS Excel, MS PowerPoint, MS Access, InfoPath Designer

Programming Languages: Structured Query Language (SQL)

Other known tools: Informatica, Load Runner, Win Runner, Crystal Ball, Expert Choice, and Testing tools Rational Robot, Rational Clear Quest Test Manager, HP Quality Centre, Quick Test Professional (QTP), Load Runner, WinRunner Apps.

PROFESSIONAL EXPERIENCE:

Confidential, North Brunswick, NJ

Business Analyst

Responsibilities:

• Write the detailed user needs, Gathered business, functional requirements during inception phase, documented and delivered functional specification documents, and assisted architecture analysis and design using UML and Rational tools.
• Design and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD (Object Oriented Design) using UML and Visio.
• Identify, researched, investigated, analyzed, defined and documented business process and Use Case scenarios.
• Conduct workflow, process diagram and GAP analysis to derive requirements for existing systems enhancements.
• Lead JAD sessions with stakeholders to analyze system needs and integrate requirement to develop a consistent navigation structure
• Work on insurance data related to Medicare, Medicaid, and Insurance claims.
• Work on HL7 to provide framework to carry out transfer of electronic healthcare information.
• Help manage risk analysis and mitigation plans, status reports, and client presentations; prepared business process models, defined milestone deliverables, and established critical success factors.
• Get exposure of IBM mainframe environment for Medicaid Management Information System impact assessment. Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider
• Gather all the needed data (table names, column names, field names, notes) from the Windows and Interfaces documents.Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.
• Prepare and maintained requirements traceability matrix (RTM) throughout the project lifecycle.
• Function as the primary liaison between the business line, operations, and the technical areas throughout the project cycle.
• Formulating the systems of project to parallel the business strategies.
• Analyze research on operational procedures and methods and recommended changes for improvement - with an emphasis on automation and efficiency.
• Write SQL queries in MS Access for data manipulations.
• Assist with user testing of systems, developing and maintaining quality procedures, and ensuring that appropriate documentation is in place.
• Develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Use Test Director with QA team for testing.
• Interface with SME's to prepare BPR documents for ongoing projects

Environment: RUP, MS Project, ANSI X12 - EDI, Rational Rose, HP Service Desk, MS Visio, MS Word, MS Excel, Medicare, Medicaid, Rational Requisite Pro, SQL.

Confidential - Denver, CO

Business Analyst

Responsibilities:

• Good working knowledge of HIPAA ICD10 and HIPAA transaction requirements. Experience with commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications
• Strong understanding of medical coding and transition from ICD9 TO ICD 10
• Accomplished projects and design documents on HIPAA 835 and 837 calculations and EDI transactions, Health Statements and Explanation of Benefits, Healthcare Reform and 5010 CMS occurrence and field expansion for 835 and 837 EDI formats.
• Experience with Healthcare systems like FACTES in various areas like Enrolment, Customer Service, Billing and Network X Pricing
• Experience with claims process and adjudication in the Private Insurance Sectors
• Solid experience in Claims Processing 837 transactions and remittance 835 EDI files
• Good knowledge of Health Plans managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and Disability claims in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Maintained pricing configuration in Facets Systemfor Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Adept with different methodologies which include Agile, Waterfall and Rational Unified Process (RUP)
• Well versed in Requirement Gathering through techniques such as JAD sessions, Interviews, Document analysis and Reviews
• Expertise in documenting Business requirement document (BRD), Functional and Non-functional requirements, Requirement Traceability matrix (RTM), Use case Specifications and the complete System Requirement Specifications (SRS)
• Design and development of Use Cases, Activity Diagrams and Sequence Diagrams using UML
• Creation of data flow diagrams (DFD) and interpretation of ER diagrams
• Creation of aGap/Impact Analysis Document for changes of the EDI Transactions (837, 835, 276/277, 270/271)
• Creation ofGap/Impact Analysis and Operational AnalysisDocument for Medicaid Subrogation. Creation ofGap/Impact Analysis Document for the Prescription Drug Point ofSaleSystem.
• Expert in Tracking and Managing the Requirements using Requirement Traceability Matrix (RTM) that controls numerous artefacts produced by the teams across the deliverables for a project
• Tested and delivered Inbound/Outbound Facets interfaces
• Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
• Experienced with current industry standards such as HIPAA, LOINC and SOX
• Involved in meetings for Test Planning, Test Preparation, Test Execution and Issue Resolution and Report Generation to ensure that all aspects of a Project are in Compliance with the Business Requirements
• Implemented automated COB processing of Medicare claims into Facets.
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Reviewed Test plans to make sure all the requirements have been covered and corresponding test cases have been created
• Involved in training of end users
• Documented Training Manuals for new product releases
• Excellent analytical & problem solving skills and a team player with strong interpersonal and communication proficiency
• Involved with long term projects from the requirements gathering phase to the implementation phase
• Interface with clients from Operations, Marketing, Sales, Technologies, and Outside Vendors and act as their customer interface point as the lead of the Projects
• Highly motivated team player with excellent Interpersonal and Customer Relational Skills, Proven Communication, Organizational, Analytical, Presentation Skills, and Leadership Qualities.

Environment: EDI, HIPAA, Windows NT, UML, Facets Trizetto, ERWIN 4.0, SQL, Rational Requisite Pro, Test Director, MS Project, MS Office Suite.

Confidential - Groton, CT

Business Analyst

Responsibilities:

• Understood and articulated business requirements from user interviews and then converted requirements into system requirements.
• Designed and developed business flow diagrams, wireframes, mock ups, user interface design, activity diagrams, sequence diagrams, Object Oriented models using MS Visio.
• Conducted JAD sessions with end user community ensuring that the software addressed all business needs, analysis of the potential users of the system either through discussion.
• Clarified client requirements, business needs and project objectives, via feedback sessions and client meetings, in collaboration with all stakeholders.
• Collaborated with Sales and Marketing teams, external ad agencies, third-party technology distributors to facilitate communication for successful project launches.
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Responsible for converting the programs from 4010 to 5010 version for HIPPA standards, there was also included the NCPDP 5.1 conversion for drug claims.
• Assisted Design Team in preparing SSR, Software Design Document (SDD), User Interface Design, Application Architecture and Database Modeling
• Create, develop and manage content for organization's web presence (requires working with content management software)
• Strategized project scoping and specifications documents, logical data model, to clearly communicate the project roadmap.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables
• Met with all developers, offshore team and project stakeholders to lead a kickoff meeting. Defined and introduced the project, team members' roles, and key deliverables. Mapped out timelines, milestones, communication processes, question and answer session.
• Generated excitement and buy-in to secure commitment to project objectives, and shared a group vision to start the team on a motivated track

Environment: MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio, BIE), MS-Project, Windows 2000, Business Objects, SharePoint, Adobe CS3, Microsoft EDW, MS SharePoint, Six Sigma, .Net 4.0, RUP, Agile, SDLC, TFS, Microsoft Test Manager.