SUMMARY

• Experienced Senior Business Analyst with 8 years of proven skills in requirement gathering, interacting with developers, documenting various business processes, executing test plans, coordinating various projects contributing 3 Years of experience in Medicare D in region of Healthcare IT Industries.
• Proficient with EDI translators, EDI and FTP standards, ANSI X12/EFIDACT and XML, Claredi Ultra Edit & Trizetto Facets
• In - depth knowledge of best practices in Affirmative Action/Equal Employment Opportunity, HR information systems (HRIS/HRMS), functional human resources management and operations, recruitment and other business processes including applicable federal, state and local laws and rules.
• Excellent knowledge working on various Trizetto FACETS Modules.
• Comprehensive and proficient knowledge of EDI X12 Standards in Healthcare
• Concrete understanding of Business Requirement gathering, Business Process flow, BusinessProcess Modelling and Analysis, design documentation.
• Excellent knowledge of ICD9/ICD10,Epic Build, Epic Clinical Workflows, Epic Implementation, Revenue Cycle, Provider, Professional, Facility, COB, Medicare/Medicaid Claims, HL7 Interface Messages, Split Claims, Medical Necessity, Dual Coding, … TA1,999 … 820 EDI Transactions, EOB, EOP, Claim Adjudication, FACETS & NASCO User Interface.
• Completed Training in Epic Bridges Interface module in Madison, WI.
• Very good working experience on Nasco and Facets Claims Processing system
• Functional knowledge in Creation of Professional and Institutional Claims by generating Flat files using NDM input/output folders.
• Extensively involved with the NASCO - HIQK, HEHK, and EFDE applications
• Operational experience in HealthCare Provider & Payer Industry-EPIC Implementation, Membership, Eligibility, Claims, Billing and Reimbursement.
• Extensive experience working in all stages of System Development Life Cycle (SDLC). Extensive experience leading, facilitating conducting Joint Application Development (JAD) sessions among user community, stake holders and technical management, creating project plans and schedules and managing changes.
• Analyzed and synthesized results from Joint Application Development (JAD), proposed alternative tasks and transformed those into Business Requirement Document (BRD).
• Solid working experience in Backend Testing using SQL Queries on various databases such as Oracle, MS SQL Server
• Around 2 years of experience in Test Automation using QTP (9.2 to 10.0 versions)
• Good exposure in using of QTP Integrated Environment (Step Generator, Synchronization, Actions, Recovery Scenarios and Methods etc )
• Proficient working on Various EPIC Modules used in Hospital Organizations and Providers.
• Expertise in building ICD10 Test Scenarios and Test Scripts from Epic Workflows in all Epic
• Applications like ADT Prelude, Op Time, ASAP, Cadence, Epic Care Inpatient, Ambulatory, Beacon, Resolute Hospital (HB) & Professional Billing (PB), Anesthesia, Radiant, Patient's My Chart Activation, Beaker, Stork, Willow, HIM Coding, Tapestry & Cupid.
• Involved actively and had experience with one complete Implementation Cycle of Epic EMR.
• In Depth Knowledge on Working of Cerner-McKesson Application which includes Surg Net(Surgery), PathNet (Lab/Pathology) & Rad Net (Imaging) Modules and Processing of
• Excellent knowledge in Software Development Life Cycle (SDLC) / Rational Unified Process (RUP) methodologies, Agile Methodology.
• Preparing graphical depictions of use cases including State Diagrams, Activity Diagrams, Sequence Diagrams, Use Case Diagrams, Component-Based Diagrams, Collateral Diagrams, including the Business Workflow Chart.
• Experience using Rational Rose and MS Visio for business process modelling and designing data flow diagrams (DFD).
• Very sound knowledge in HP-ALM QC for Test Planning and Test Asset Management throughout the Software Development Life Cycle.
• Excellent knowledge working on Team Foundation Server (TFS) for creating Sprint User Stories, Queries, Bugs and maintaining overall project status
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules such as EDI … &820.
• Sound Knowledge in Processing of 834 EDI Transactions.
• Proficient inICD-9-CM and ICD -10-CM coding and Claims processing
• Expertise in Agile/Scrum methodology in Testing, including Sprints, Stand-ups, Story board, User Stories, Defect Tracking
• Proficient in working with testing tools like Rational Quality Manager, Clear Quest, HP-ALM/QC
• Involved in preparation of Defect Report and Weekly Status Reports
• Excellent Analytical, Organizational, Interpersonal, Communications, teamwork and leadership skills with proven skill to interact across multiple levels of organization.
• Good Team Player and a Self-starter with excellent verbal & written, analytical & documentation skills and Ability to quickly master new concepts and applications
• Thorough knowledge in Requirement analysis, Planning, Scheduling & Tracking projects.
• Hands on experience of using MS Office Suite, MS Project, MS Visio, Rational Tools.
• Enjoy working in a Collaborative, Fast Paced Environment

PROFESSIONAL EXPERIENCE

Confidential, Englewood, CO

Sr.Business Analyst

Responsibilities:

• Involved extensively and hands on experience in building ICD10 epic Test Scripts in both Inpatient and Ambulatory Settings and for Revenue Cycle Applications like 3M Coding, Professional, HospitalBilling and Claims portion by reviewing Epic clinical Workflows, visios and Epic User Web documents.
• Liaison between Information Systems and the HRIS, Human Resource, and Payroll Departments as it relates to the computing systems that are in use
• Co-ordinated and assisted the Project team in executing the Test Scripts in EPIC Software.
• Had daily team meetings with Project Manager and updated the daily team status
• Created Test Plan, Test Scripts in Excel spreadsheet and uploaded them to HP-ALM/Quality Center Test Plan module using ALM Export Wizard.
• Maintain applicant tracking system, HRIS Master Tables, notifications, job catalog and assessment administration, department and position codes, job seeker and access setup
• Tracked RAC audits through an electronic JDR system that housed all documentation received from the Medicare Administrative Contractor (MAC) as well as the results of each case
• Built and Performed Scripts for Outpatient Registries, Scheduling Appointments, Check-In, Nurse Rooming, Ambulatory physician Orders, Check-out in Epic Care Ambulatory module.
• Moved Test Scripts from Test Plan to Test Lab module and performed them in EPIC System and updated the Test results in ALM Test Lab Module.
• Logged various Defects and conducted Defect Review meetings with SME's and updated the Status of the defect from time to time in Defects Module in ALM
• Involved in automation infrastructure development in Quick Test Pro
• Extensively involved in Regression testing using QTP 11.0 Version.
• Generated Score Card Reports in ALM stating daily work progress and sent to Project Team
• Hands on Experience working in performing the scripts related to Patient Admit, Transport to ahospital, Discharge of a patient (ADT), Coding of a Patient Account, Billing of an account and finally generating and sending Claims to the Payer
• Used Quality Center to write, execute and management of test cases and defect tracking.
• Built Test Scripts for Patient Transport using AD/ Prelude, Oncology Department using Epic Beacon, Emergency Department using ASAP, Outpatient using Cadence and Epic Care Ambulatory, Surgery Scripts using Op Time, Patient Admission and Stay in hospital using Epic Care Inpatient and Bed time, Managing, Verifying & Dispensing Orders as a Pharmacist using Epic Care Willow, Verifying Patient's Lab/Pathological Results using Beaker and Billing & Claims using Resolute/ Revenue Cycle Applications.
• Performed Test Scripts in Epic Test Environment for various Epic Applications to evaluate routine tasks of Charge Nurse (RN), Front Desk, Physician/Surgeon (MD), Central Scheduler, Unit Clerk, Registrar, Supervisor, Lab Technician, HIM Coder, OR Biller & Pharmacist using appropriate Log in Credentials.
• Responsible for creating the ICD9 to SNOMED data mappings and creating the new SNOMED Master table.
• Runs the billing compliance program carrying out complex compliance activities to maintain and follow guidelines designated by Inova and the Center of Medicare and Medicaid Services (CMS)
• Oversaw & supported Medical Records, Quadramed Affinity Patient Scheduling, Patient Registration, Order Entry, Clinical & Patient Revenue Cycle Applications, Medicare ancillary billing components of Laboratory & Radiology Medicare ancillary billing (Lab/Rad), Quadramed Affinity Patient Accounting, Accounts Receivables & Medical Records Financial Systems Management.
• Conducted Script Reviews with SME's for various ICD 10 Impacted Scenarios for Epic ADT, Bridges, Ambulatory, Inpatient, Op time, Beacon, ASAP, Cadence, Stork, Anesthesia, Resolute PB&HB modules
• Validated DRG's, Diagnoses and Procedure/CPT Codes to be compliant with ICD-10 version in Epic Test Environment in order to ensure proper Billing and Reimbursement from the Payer.
• Conducted Test Scripts Sign Off Meetings with SME's to ensure all affected Epic areas related to ICD10 are included in the script for System, Interface and End to End Phases of Testing.
• Arranged meetings with Subject matter Experts (SME's) and the development team regarding the defects found and their resolution in ALM QC Defect Module.
• Involved extensively in building epic ICD 10 test scripts and performing for System, Interface, User Acceptance (End to End) & Payer Testing.
• Extensively Validated various ICD 10 impacted HL7 Interface messages generated between 3rd party applications( Ensemble) and Epic Applications (ADT, ASAP, Outpatient, Inpatient, Pharmacy) and communicated effectively to ensure No loss of Data Integrity using Epic Bridges.
• Validated the Reports of the Patient's Imaging Orders (Ultrasound, CT/MRI Scanning, EKG/PACS) placed by a Physician under Radiology Department using Epic Radiant Application
• Written and Executed Test Scripts in Epic Implementation Application for Diagnosis Calculator which is a newly implemented system in EPIC ICD 10 Application Software in order to validate the Specificity of ICD 10 Diagnosis (Dx) and CPT/Procedure (Px) Codes.
• Performed Admitting Labor & Delivery Patients logging as OB Nurse and documented C-Section Procedure Results logging as an Obstetrician in Epic Stork Test Application Environment.
• Functional knowledge in Signing up Patient's My Chart Activation to access their Medical Records. Expertise in Coding a Discharged Patient Account using 3M Software and coded appropriate Diagnosis, Procedure and DRG associated with patient's problem and verified charges posted using HIM (Health Information Management) Module.
• Efficient in creating Test Summary Reports at the end of each Testing phase of Validation.
• In Depth Work Knowledge in Revenue Cycle Billing Workflow to view required Charges posted to the patient's Guarantor account and then to Payer (Insurance) on Charge Review Work queue.
• Very sound knowledge working on creating Professional & Hospital Electronic Claims and to verify accurate ICD 10 Diagnosis and Procedure Codes are filed in order to ensure proper Billing and Reimbursement from the payer perspective in Epic Tapestry module.
• Verified Diagnosis Calculator- a new ICD10 epic tool which is required to choose appropriate administrative details when a generic or Non-Billable diagnosis code is used for Billing.
• Excellent functional work knowledge on evaluating Medical Necessity for Medicare accounts and profound work experience on Split Claims for Inpatients, Outpatients, Observation and Emergency encounters i.e. Dual coding and Validating two separate claims generated for the encounter who admitted prior to 1st Oct 2015 billed with ICD9 Codes and who discharged after 1st Oct 2015 billed with ICD10 Codes for the accurate Billing & Reimbursement from the payer.
• Involved extensively in directing and escalating the issues/defects found during testing with Subject Matter Experts from Epic headquarters located in Madison and resolved them.
• Sound knowledge working on dual coding the accounts in ICD-9/10 to validate the specificity and accuracy of the system and its impacts from the Billing and Claims perspective.

Environment: EPIC, HP-ALM, HL7, EDI X12 Standards, SNOMED-CT, LOINCSql, .Java, Oracle 11g,, Use Case, Toad, SQL, MS Office Suite(Word, Excel, Power point)

Confidential, Beaverton, OR

Business Analyst

Responsibilities:

• Responsible for business process analysis that includes requirements facilitation, definition & analysis, Business process design and data mapping.
• Involved in configuration of FACETS Subscriber/Member application
• Worked on Facets Data Tables like (MEES, MEME, BLEI, MESU, BLDF etc;) and created audit reports using queries.
• HRIS troubleshooting for Lawson
• Performed Data mapping and data modelling and used Canonical data model to map data from X12 834 transactions
• Performed forward and backward data mapping between fields in Mainframe and Facets
• Tested the changes for the front end screens in FACETS related to Membership, Benefit and Plan modules.
• In order to keep up with competition and grow the business to a higher level of potential, we developed and tested a database using Microsoft Access and different testing Management tools such HP Quality center, and Clear Quest. Also, acted as a liaison between the group member and the stakeholders.
• Analyzed the mainframe Reports for Member/Eligibility/Claims and mapped the fields with Facets batch jobs and reports.
• Manually loaded data in FACETS and have good knowledge of Facets Business rules
• Worked extensively on Claredi's system to trace out the exact root cause of Errors in the 834 test files.
• Converted X12 834 files using Ultraedit tool in a readable format to understand the exact 834 file structure.
• Strategized a project to develop Business Process Engineering/Re-Engineering solutions to increase revenue using Revenue Cycle tools & applications.
• Used Mercury Quality Center to look up defects and issues raised by testing activities.
• Involved extensively in writing Agile User Stories in Team Foundation Server (TFS) and reviewed with Business lead and project manager for Sign Off
• Extensively worked on creating Business Requirements Documents (BRD's) and Technical Specification Documents.
• Participated in daily Scrum Meetings to review the Business, functional and Non-Functional Requirements and to discuss the status of Product/Sprint Backlogs.
• Participated Actively in Sprint Planning Meetings to discuss about the User Stories, Story Points and Product/Sprint Backlog created and had Brain Storming sessions with Product Owner, PMO's, Developers and Business Users
• Extensive knowledge of Patient Protection and Affordable Care Act (PPACA)
• Trace and inform business requirement changes through the lifecycle of the project using Rational Requisite Pro while maintaining customer needs and maintain a Requirements Traceability Matrix (RTM) to keep the stakeholders informed of the progress of the project.
• Understand and have the ability to configure, test, and resolve transmission set up for standard files (SFTP, FTP)
• Hands on experience with the 834 ANSI X12 transaction understanding loops, segments, elements and structure
• Extensively participated in verification of EDI file formats against HIPAA ANSI X12 Standards
• Maintained Excellent team collaboration with Developers, QA Team and tracking from time to time regarding the status of the bugs detected and updating them in TFS.
• Gathered detailed business and technical requirements and participated in the defining the businessrules and data standards.
• Transform business requirements or policy documentation into Features, test plan, test cases and scenarios.
• Extensively worked on Data mapping of EDI Segments from 834 FFM (Federally Facilitated Marketplace) to Facets database and vice-versa.
• Copied 834 files received from FFM (Federally facilitated Marketplace) to a specific folder for further processing and finally installing enrollment data to Facets.
• Extensively involved in gathering Reconciliation files and sending them to FFM for further analysis for unpaid members.
• Analyzed and compared data present in HIX Middleware Canonical (BizTalk/Windows Service Bus) to Facets by writing SQL Queries.
• Excellent knowledge creating and working on Change In Circumstances (Cic834) and Reconciliation Scenarios and User Stories in TFS.
• Sound knowledge working on Facets UI in processing and validating Enrollment, Subscriber Eligibility, Claims and Membership Data.
• Profound Knowledge working on Inbound (I834) and Outbound (IC 834) 834's according to FFM (Federally Facilitated Marketplace) and Issuer perspective.
• Hands On experience working on 820 Payment order Remittance Files in order to validate the 834 Enrollment payment data to and from CMS.
• Excellent knowledge working on 834 Re-enrollments/Renewals and Reconciliation member data

Environment: FFM, HIX Middleware, TFS, Facets, Biz Talk, Dot Net, EDI, Quality Management HP ALM, Quality Center, RM Track Microsoft Excel, Visio, One note, SQL, Windows Service Bus, Microsoft Test Manager (MTM).

Confidential

Business Systems Analyst

Responsibilities:

• Involved in analyzing Business requirement documents, Claims Xten Use Cases and Conceptual System document (CSD) to identify specific requirements for In scope and Out of scope.
• Responsible for understanding and documenting requirements and translating them to functional and non-functional specifications and verifying that solutions meet the requirements.
• Created the Test Plan document which describes about the Test Strategy, In-Scope, Out of Scope, Assumptions, Risks, Dependencies and Timelines etc.
• Developed Test Plan, Test Scenarios and Test cases that reflects business requirements and reviewed with Test Lead and Business End users to get sign-off.
• Expertise in Creating Professional and Facility Claims required for Test Execution by generating Flat files using NDM input and output folders.
• Developed various UAT Test Scripts for testing HIPAA 835, 834, 837(I/P), 270/271, and 276/277 EDI transactions in order to generate a wide variety of Valid Claims.
• Expertise and In-depth knowledge of Claim Adjudication & Post Adjudication Process (Payment Order remittance, deductibles, Carry-over, etc.)
• Expertise in Adjudicating the claims and processing them through NASCO HEHK, HIQK & HZMK application
• Expertise on working various Loops, Segments of 834 Transaction set and verifying the ST & INS Segments.
• Highly involved in working on N1 Loop for identification of Payer and Sponsor Name and if sponsor details are associated for dependent.
• Proficient working on processing 834 Files upstream and downstream, identifying Enrollment Scenarios and deriving test scripts from the scenarios and adjudicating Claims effectively.
• Using Claims xten logic, proficient in Validating and adjudicating claims in a manner that is more efficient and cost effective.
• Supported Revenue Cycle system from a billing perspective pre and post Healthquest 3.0.
• Using this logic, efficient in verifying and documenting the Incidental, Mutually Exclusive, Re bundling
• Edits identified by Claimsxten software under Test Results.
• Sound knowledge working with Explanation Of Benefits (EOB)/Coordination of Benefits (COB)/Check/EFT Transactions and Explanation Of payments (EOP).
• Analyzed the exact behavior of the ICD9/10 claim in the CXT UI Interface in order to verify that the Claim processed correctly in NASCO.
• Profound knowledge on various segments of the Claims i.e. Provider, Subscriber, HCPCS/CPT which are processed in NASCO.
• Developed the test cases for Claims xten rules and reviewed with Test Lead and Business Lead andBusiness End users to get sign off.
• Functional Experience in using IBM Rational Clear Quest for Defect Logging and tracking in IBM Clear quest
• Attended daily status meetings and prepared dashboard for daily status at the end of the day to the manager.
• Maintained the Requirements Traceability Matrix throughout the project life cycle.
• Verify the status of submitted defects, and participated in defects review/prioritization activities
• Provided detailed problem description for the issues to the development team to enable and facilitate them in proper analysis for the defects resolution.
• Worked very closely with Test Lead during entire Test Execution Phase until UAT sign off.
• Recorded and documented the Test Results for Test Cases.
• Involved extensively in discussion with Subject Matter Experts (SME's) for Test Results Review Meetings and clarified their queries actively until getting sign off.
• Attended Quality Review process meeting to document the lessons learned.
• Very sound knowledge in processing Medicare, Medic aid and Coordination of Benefits Claims.
• Conducted Daily defect meetings with Business Subject matter expert have to review the defects resolution in End to end & UAT test Phase.

Environment: Java, Oracle 11g, Clear Quest, Use Case, Toad, SQL, MS Office Suite (Word, Excel, PowerPoint)

Confidential, MO

Business Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Documented the business logic and associated validation logic.
• Created screen-mockups using iRise to review the requirements and provide feedback on the screen design. Also, used Microsoft Paint to create ad-hoc screen mock-up to review with the users.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Provided suggestions and ideas more from a strategic and long term perspective.
• Created Requirements Specification Document that translated business requirements into Technical specification including business and validation logic for ease of understanding to the development team.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Followed Agile (XP) Methodology for the release.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Used the Agile methodology to build the different phases of Software development life cycle. (SDLC)
• Moreover, I also authored functional requirements documents FRD by interacting with development team for improving client’s legacy system.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Conducted group (JAD) sessions with business units and stakeholders to define project scope and deliverables.
• Worked with the Training Group to build training materials as well provided any suggestions/ tool tips to assist in User Training

Environment: Windows XP Professional, Oracle9i, Agile, MS Access 2000, MS Excel, Six Sigma, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.

Confidential, Louisville, KY

Business Analyst/ Systems Analyst

Responsibilities:

• Involved in requirement gathering phase (Provider, Claim components and HIPAA)
• Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• Met with report users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
• Involved in understanding the current business process, defining scope of the project along with position statement.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional requirement.
• Implemented automated COB processing of Medicare claims into Facets
• Validated business rules and all artifacts with users, got approval and sign off.
• Followed Unified Modeling Language (UML) methodology using Requisite Pro and Rational Rose to create/maintain: Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams.
• Tested and delivered Inbound/Outbound Facets interfaces.
• Experience with Trizetto Facets System implementation, 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.
• Assisted Design Team in preparing SSR, Software Design Document (SDD), User Interface Design, Application Architecture and Database Modeling.
• Helped in project testing efforts for doing integration tests, regression tests and user acceptance tests.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Documented the dimensional models of ETL system.
• Worked with QA team and UAT team to go over the various test scenarios for different types of loads in the datamarts.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment.

Environment: Java, JSP/Servlet, Oracle 9i, MS Office Tools, Windows XP, MS Project, Requisite Pro, Rational Rose, Clear Case, MS Power point, MS-SharePoint, MS-Word, MS-Excel.