SUMMARY

• Over 7 years of experience in the healthcare domain as an EDI Analyst with extensive experience with all aspects of EDI applications, HIPAA, X12.
• Profound knowledge of EDI X12 standards in Healthcare Insurance. Extensive experience with EDI translators, EDI and FTP standards, ANSI X12/EDIFACT and XML.
• Strong business analysis skills and an understanding of the Software Development Life cycle (SDLC) utilizing Rational Unified Process(RUP).
• Experienced in mapping of the various ICD10 codes applicable for tracking of diseases for which diagnostic testing is done.
• Extensive knowledge of HIX (Health Insurance Exchange), EMR (Electronic Medical Records), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act(ACA).
• Expertise knowledge of ANSI X12 Healthcare transaction sets like Enrollment, Eligibility, Claims submissions, Remittance and Denials.
• Encounter/claim processing experience for both professional and hospital billing with thorough understanding of the processing rules, Fee schedules, COB rules and payment posting experience with complete understanding of the EOB and the denial reason codes.
• Experience with HIPAA technical aspects related to claims and eligibility transactions. Sound Knowledge of HIPAA privacy requirements.
• Involved in the design, development, implementation and production activities associated with the healthcare EDI transactions sets such as 270/271,276/277,820,834,837, and 835.
• Experience in developing, testing and implementing EDI transaction maps, BPML and code list to enhance the day to day transaction of EDI document both inbound and outbound to the company.
• Monitoring project risks and scope creep to identify potential problems and proactively identifying solutions to address them in advance.
• In - depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extractbusinessprocess flow.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• In depth knowledge of SDLC and implementation of the Rational Unified Process (RUP) in all four phases of a project: Inception, Elaboration, Construction and Transition.
• Experience in conducting requirement analysis, use case design, test plan designing, and developing database schemas based on the logical models.
• Team player and self-starter with excellent communication, coordination, documentation, project planning, and interpersonal skills.

TECHNICAL SKILLS

Operating Systems: Windows

Utility Tools: JIRA, Rally, MS Project, MS Visio Testing Tools Quick Test Pro (QTP), Win Runner, HPQC

Methodologies: Rational Unified Process (RUP), Waterfall, Agile/Scrum

BusinessSkills: BusinessProcess Analysis & Design, Gap Analysis, JAD/JRP Sessions

MS Office tools: Outlook, MS Word, MS Excel, MS Visio, MS SharePoint, MS PowerPoint.

Other Skills: SAS, SQL

PROFESSIONAL EXPERIENCE

Confidential, CA

Business Systems Analyst

Responsibilities:

• Gathered detailedbusinessand technical requirements and participated in the definitions ofbusiness rules and data standards.
• 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 Enrolment hence analysing and documenting relatedbusinessprocesses.
• Performed gap analysis of claims and enrolmentbusinessprocess for changes from SSN identifier to USI (Unique Subscriber Identifier) affecting for HIPAA EDI X12 transactions 837, 834, U277, 276/277, 270/271, 278,835 and 820.
• Created specifications for EDI HL7 (A28, A31, ADT) and X12 (837/835) transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers.
• Worked with data migration and file mapping for various EDI transactions. Enhanced the Provider/Patient verification criteria using additional parameters based on the information retrieved from the EDI 837 I/P transaction files.
• Translated the EDI X12 data into XML format for initial transformation/migration.
• Facilitated functional requirement gathering from system users and preparedbusinessrequirement documents (BRD).
• CreatedBusinessProcess Mapping Diagrams and Documentation for the process improvement recommendations.
• Used MS-Visio for flow-charting, Use- Case process model and architectural design of the application.
• Implemented the Rational Unified Process (RUP) methodology guidelines with its various workflows and artifacts in Requirements Management and Development.
• Gathered and documented functional requirements and use cases for automation of operational and administrativebusinessprocesses.
• Provided overall project management to multiple projects successfully completing them on-schedule and on-budget.
• Documented the "AS-IS"BusinessWorkflows adhering to UML standards. Conducted JAD sessions to define requirements and finalize the Functional Requirement Document (FRD).
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML and Visio.
• Interfaced with team leaders, identify and analyse the given information, procedures and decision flows, evaluated existing procedures, methods and technical documentation. Communicated with executives, managers and other stakeholders regarding project scope.
• Responsible forbusinessprocess analysis that includes requirements facilitation, definition & analysis, alternatives, software selection, prototyping,businessprocess design and mapping.
• Maintained a Traceability Matrix to ensure that all functional requirements are addressed at the use case level as well as the test case level.
• Involved in identifying use cases, actors and writing use case narratives. Created use case diagrams and activity diagrams using MS Visio.
• Conducted meetings and JAD sessions for project definition, resource identifications and deliverable prototype identification.
• Interfaced with developers,analysts, customers and project managers to discuss requirements and recommended solutions, to help resolve issues.
• Led the User Acceptance Testing efforts to verify that the developed reports meet the requirements.
• Involved in developing the test strategy and helped in developing QA Test plans for Functional, Integration and System Testing.

Environment: Quality Center, Excel, Outlook, MS Office, MS Project, project management, Rational Rose, Rational Requisite Pro, RUP, UML.

Confidential

Business Systems Analyst

Responsibilities:

• Created Vision, Scope, and Use Case documents,BusinessProcess Models, System Models depicting software architecture and interaction of system components.
• As a Project Manager/BusinessAnalyst, was responsible for all aspects of project management, including the development and management of the system requirements.
• Convertedbusinessrequirement into functional requirements. Prepared detailedbusiness specifications for development of systems.
• Extensively worked on EDI transaction like 837, 835,834, 820, 270, 271, 276, 277 and 278.
• Liaison betweenBusinessStakeholders, and 820, 834, 835, 837, 277 and 999 Transaction Tower Leads.
• Involved in historical data fix and data recovery/replay operations for reporting clean-up of HIPAA Compliant EDI transactions 270/271, 276/277, 837, and 835.
• Created and maintained data mapping document(s) about the HIPAA transactions: 270/271, 276/277, 837, and 835.
• Provided services to the Center for Medicaid and Medicare Services (CMS) for the Affordable Care Act (ACA), assisting with the software implementation of the Federal Health Insurance Exchange.
• Assisted both Medicare and Medicaid programs with their NCPDP Standard use and modification request. Documented Medicare claims processing.
• Elicited, documented and managedBusinessand System requirements for HIPAA 5010 version 837, 834, 835, 270, 271, 276, 277 transactions through requirements gathering sessions with stakeholders.
• Worked on Healthcare transactions like 820 - Premium Payments and 834 - Enrolment and Dis-enrolment in Health Plan.
• Responsible for membership analytics, billing and enrolment, medical capitations, medical expense projections, risk pool development, and for developing and analysing other claims projects.
• Functioned as the liaison between Eligibility Medicare Operations and internal cross-functional partners including Product, Finance, Communication Fulfilment, Vendor Management, and other Client Services Teams.
• Responsible for identifying HIPAA 837 claim XML historical Hospital claim data to assist in the development of impact analysis and trending analysis.
• 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 Enrolment hence analysing and documenting relatedbusinessprocesses.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• PerformedBusinessProcess Mapping and performed AS IS and TO BE analysis.
• Involved in creating Project Management Documentation, followed PMBOK Standards.
• Tracked project related data/issues and report it to project management. Regular collaboration with PMO on project management, project delivery, process governance implementation, operational risk assessment; facilitated Vision workshops and JAD sessions.
• Involved in developingBusinessRequirement Document, System Requirement Specification document for application development.
• Maintained Requirement Traceability Matrix, Change Requests. Coordinated work plans between project manager and stakeholders using MS Project.
• Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams.
• Coordinated Joint Application Development (JAD), Interview sessions with stakeholders throughout SDLC to resolve open issues.
• Worked with QA team to get technical designs developed by application and database developers validated against functional specifications.
• WroteBusinessRequirements Documents (BRD) and Functional Requirements Specifications (FRS) documents.
• Facilitated meetings with product, compliance, operations, vendor and technology stakeholders to define, review and obtain sign-off for Scope Document.
• Defined Use Cases and Process flows for new functionality and documented them inBusiness Requirements Document
• Conducted Walkthroughs and User Acceptance Tests (UAT) and worked closely with the UAT personnel to both ensure that their needs are met.
• Communicated requirements through visually modelled UML diagrams to both management and development teams.

Environment: MS Project, MS Office, Rational Suite, project management, MS Visio, Requisite Pro, ClearQuest, RUP, UML.

Confidential

Claims system Analyst

Responsibilities:

• Responsible for updating the IDX masters for the accurate CPT, ICD Codes and descriptions.
• Was responsible for encounter processing for both professional and hospital billing.
• Was involved in updating the provider masters and the locations masters and the fee schedule and pricing masters.
• Reviewed and identified any coding changes as per the Annual AMA CPT updates and regulatory changes.
• Worked in coordination between the different teams coding, billing, posting and denial teams to identify the accurate descriptions and changes or deletion on the pricing and for global procedures listings.
• Ensured that the billing software is accordance to the government policies and guidelines.
• Responsible for periodic review the scrubber report to ensure for any IDX claim submission issues.
• Generated different provider financial reports, charge summary and rejection reports.
• Assisted the coding team to resolve any diagnosis or procedure coding issues by providing adhoc reports on denials for coding issues.
• Responsible for a payer wise report on the total charges billed amount and the payments received.
• Assisted in strategic pricing process to optimize reimbursement within budget guidelines.
• Assisted in trouble shooting and resolving any issues in the patient revenue cycle management and suggested recommendations to the management.