SUMMARY

• Senior Business Analyst with over 15 years of Healthcare experience and Business Systems Analysis experience with commercial and public sectors.
• Experience in business operations, systems analysis and creating technical documentation pertaining to all SDLC phases.
• Management experience includes system implementation, configuration of systems, process engineering, management of analysts and programmers, interfaces between systems.
• Strong knowledge of Power MHS, NASCO, FACETS, and other healthcare and business tools.
• Projects worked on have included HIPAA transactions ( Confidential ), End to End implementation of various projects ( Confidential, Confidential, Dept. of Veterans Affairs), Upgrade to later version of System ( Confidential, BlueCross of MN, Confidential, Confidential ), Use of various tools to test, record, execute, and track defects (All).
• Worked on various Line of business Medicare and Medicaid, Healthcare Claims processing. Experience in Provider, Payer and Government - CMS line of business.
• Additional areas of expertise include Analyze business & technical processes, Business Process Reengineering; Business Performance Improvement, Documentation experience in IT specifications, business rules & flows and used case
• Extensive knowledge on Context Data Flow Diagram, Entity Relationship Diagram, Process Decomposition Diagram, Workflow Diagramming
• Concentration on Membership, Billing, and Claims.
• Data Modeling and business process flows using Office tools.

TECHNICAL SKILLS

• NASCO (3270 IBM MAINFRAME)
• Members Edge/Metavance (HP Product)
• FACETS 5.01
• TRMS reports
• Clarity
• HSD Diamond 950
• Managed Health Care systems (MHS)
• EXTOL (KC400)
• Power MHS
• ECM
• COBOL
• ECMap and GAPExpress Tool
• SharePoint
• SQL
• Sybase EC GATEWAY
• Windows 2010 Office Suite
• Access
• Excel
• Visio
• Lotus Notes
• ULTRA EDIT
• Clarify
• IBM Blueworks Live
• Rational
• SAS
• MACESS
• Crystal Reports 9
• NAMI
• SAP Business Objects 4.1

PROFESSIONAL EXPERIENCE

Confidential, Chapel Hill, NC

Sr. Business Systems Analyst

Responsibilities:

• Analyze large amounts of data to report any irregularities and make recommendation for process improvement.
• Reports for IPPR and Payment Table pulled daily and sent to operations.
• Run query of daily/weekly reports of claims paid and Claims Payment report for Medical and Dental is sent to management.
• Compile data for claims paid for Treasury team.
• Unbilled member list is pulled using Teradata tool, updates to the SQL program made and the finished report is sent to Membership Operations team.
• Training on using the Crystal Reports version 9 and Dashboard Gear (DBG).
• Identify root cause of any issue, make recommendation for improvement.
• Work closely with other members of the team to improve business process/methods.
• Contribute to the procedures and any value-added practices.

Confidential, New York, NY

Benefits Design Analyst

Responsibilities:

• HIX (Healthcare Exchange) and ACA (Affordable Care Act) - Requirement gathering sessions affecting several high profile projects within the company. The projects include State subsidy payments as it relates to Medicaid and Medicare and Nursing Home and CHP recipients.
• Updates to member tables as it relates to HIX and ACA.
• Design flows to demonstrate how enrollment will be affected (current state vs. future state)
• Writing UAT script for several projects for Enrollment, Finance (Billing), and Member Services.
• Run daily member billing queries and share the reports with the supervisors and managers.
• Run Weekly Enrollment queries from Dashboard and reconcile the member data. Forward the validated documents to Upper Management.
• Run Monthly Billing and Enrollment queries and produce a performance review document that highlights the percentage of adds/cancels/disenrollment. The report is being sent to Upper Management.
• Attend project meetings and provide status to the management team.
• Work with internal/external entities including IT team to be sure changes/updates implemented on timely manner.
• Using Business Objects to schedule daily/weekly/adhoc reports for management.

Confidential

Business Analyst

Responsibilities:

• Assisted in producing the RMP (Requirements Management Plan) documentation, which identified the roadmap and requirements process end to end.
• Prepared ‘Onboarding Documentation’ for the new team - designed a document that contained explanations and examples for each part of the FY14 BRD, i.e.: Business Process Diagrams
• Drafted pre-workshop surveys to determine the level of expertise for each identified business individual.
• Participated in daily status meetings and weekly business meetings.

Confidential

Business Systems Analyst

Responsibilities:

• Analyzed the ‘Current State’ documentation for types of programs available within the Confidential organization and certain State Mandates (i.e. Medicare).
• Conducted meetings with Business SMEs to define the ‘Source Code’ and any other relevant information (SOPs, flows, etc.) That would assist in the Facets 5.01 upgrade process for a variety of programs/plans within Confidential .
• Analyzed the source code and determined whether it had any impact on the Facets 5.01 upgrade.
• Shared analysis with programmers and helped them to determine on their end whether there would be an impact to the upgrade.
• Shared results with Business Management and incorporated their feedback into ‘Updates’ matrix and posted it on SharePoint.
• Participated in daily team and weekly business status meetings.

Confidential

Business Analyst

Responsibilities:

• Analyzed the current data provided from BRD (Business Requirement Document) and CSD documents.
• Conducted meetings with business SMEs and gathered business rules and requirements for Member Billing.
• Wrote out the Test Billing Scope and reviewed the Test Plan documents based on the data provided.
• Create Test Scenarios from the Billing Scope document and created Test Cases from the Test Scenario document.
• Using the Metavance 2.10 Model Office tool, executed the Test Cases and provided feedback to the business and team.
• Used Mercury Quality Center to execute and track defects.
• Conducted daily meetings with the Billing team to provide information and discussed action items at the weekly team meeting with other areas such as Correspondence, Finance, Reporting, and Contracts.

Confidential

Project Business Analyst

Responsibilities:

• Analyzed the current state tasks and processed for each stakeholder such as Benefit Coding and Testing, PIBA, Sales, Enrollment, Account Implementation, and Contract Administration.
• Conducted walkthroughs with business SMEs and gathered business rules and requirements for each area.
• Analyzed the current state flows, processes, task lists, and SIPOCs obtained from each business area and incorporated it into the BRD (Business Requirement Document).
• Met with the Architect and other team members to discuss future state for the above mentioned processes.
• Using IBM BlueWorks Live, created AIE2E process flow (swimlane) format for each business area in future state.
• Conducted JAD Sessions to cover the process flows and get sign off from the areas.
• Provided meeting minutes and project status to the team.
• Used Business Objects to schedule and run specific reports for different teams.
• Created Use Cases.
• Used Mercury Quality Center to execute and track defects.

Confidential

Project Business Analyst

Responsibilities:

• By looking at the variety of required output reports, identified gaps between the legacy systems Latron and mapped known elements to NASCO proprietary format.
• Studied the current and future state documents and gathered the requirements needed to prepare the Business Requirement Document.
• Using the Latron Reporting Data Warehouse (historical data), compared NASCO DB and forwarded the results to the IT team for evaluation and updates to the system.
• Conducted walkthroughs with Business and Dental SMEs to verify needed elements for migration to the new system.
• Drafted workflows, process flows and context diagrams using Microsoft Visio.
• Prepared test scripts for the technical analyst to run using the Mercury system.
• Worked with the technical team to produce the Technical Requirement Document.
• Within the BRD (Business Requirement Document), wrote detailed description of user needs, program functions, and steps required to develop or modify computer programs.
• Oversaw acceptance testing, developed user guide and provided user training; supported the user in the development of work processes.

Confidential

Senior IT Analyst

Responsibilities:

• Researched, prepared and presented reports and Functional Specifications that addressed requirements, issues, alternatives and recommendations associated with the development of existing and new business application, FACETS version 4.71
• Analyzed Business Requirements to identify key demographic data fields for testing migration into the FACETS 4.71 Enrollment, Billing and Claims system application.
• Met with DBAs, various departments, TriZetto QA consultants, IKA consultants, and other key end users to assess and define business objectives, process implications and system requirements.
• Identified process or applications issues, assessed alternative solutions and facilitated resolution of project related issues/barriers.
• Participated in design sessions aimed at prototyping new business applications in support of business objectives.
• Collaborated in the planning, development and deployment of new or enhanced core business applications.
• Utilized Business Objects 6.5 to create and run queries in order to select, arrange, and analyze data that is stored in one or more files.
• Use of Facets Analytics solution to generate queries and provide data on Eligibility and Membership.
• Validated the CDH error reports (batch files run the night before) daily and using Access 2000, created various reports from database (i.e.: terms from fac rpt) and e-mailed it to the team.
• Used MMS (Membership Maintenance Subsystem) data to perform batch job testing.
• Mentored and trained other consultants on FACETS 4.71 and Enrollment/Product configuration.
• Logged issues and tested results using Clear Quest (CQ).
• Quality Assurance to troubleshoot any other defects that occurred during testing and implementation of the project.

Confidential

Senior Business Analyst

Responsibilities:

• Account Manager for Baltimore City Public Schools. Managed end to end process from on-boarding of new group via 834 direct, third party, and paper to testing and production ready.
• Created high level flows that defined the life cycle of a new account (group) implementation or changes to an existing group.
• Created detailed flows that explained the incoming file (834, or paper) and the steps it must go through to be HIPAA and Confidential compliant.
• Tracked and analyzed any account issues and identified their root cause and shared findings with the team.
• Account management and maintenance for groups that have already transitioned from paper and FACETS 4.3 to NASCO and Member’s Edge platform.
• Managed the migration of dental records from Confidential standard FACETS 4.3 to FACETS 4.5 (TriZetto’s 834 HIPAA layouts).
• Worked with other departments such as Claims to ensure procedures were covered for groups as explained in Benefits Charts in members’ evidence of coverage.
• Used tools such as NASCO’s MD 3270 Mainframe, Metavance (Member’s Edge), and FACETS 4.5 to confirm and update members’ eligibility and benefits and identify issues and resolve them.
• Using the Confidential ’s template, created UAT Test Scenarios to identify end to end process for Member Eligibility and Billing process in Metavance.
• Created Test Cases to further identify (deep dive) every test scenario for the business when looking up eligibility.
• Monthly audit of all active accounts using the reports from Enterprise Data Warehouse. Compared the report outputs for Confidential actives vs. the actives sent by the client.
• Used the DW for Online Analytical Processing (OLAP) and queries. The historical data was then forwarded to the Users (SMEs) for business decisions.
• Used Business Objects to run queries and identify defects such as required data that was not populated in the report.
• Used Mercury Quality Center tool to record and track defects based on the UAT test results.
• Created a Traceability Matrix document to keep track of deliverables and project plans and tasks for assigned accounts.
• Daily validation of batch files for Enrollment and Billing and discussing errors with internal and external parties.
• Created Confidential proprietary group structure (breakdown of benefits) and checklist (accounts’ information) and test scripts to ensure proper mapping.
• Applied the EDI Gateway software that translated data to proprietary formats (XML and Flat files) and sent the data to the technical team to analyze.
• Attended inter-departmental meetings to discuss the impact of changes to various members within the groups and share updates to the accounts’ group structures, age limit for dependents to 26, in corporation of domestic partners benefits.
• Attended and conducted JAD sessions on new audit tools, group structures, and updates to existing templates.
• Trained new BAs on Confidential NASCO and FACETS systems and shared SOPs.
• Worked with internal and offshore programmers in creating new tools to ease the auditing process.

Confidential

Lead EDI Consultant

Responsibilities:

• Processed the daily Inbound and Outbound test claims.
• Ran reports using PowerMHS to analyze the data for subscribers and family for migration initiatives.
• Documented the testing steps and production procedures for inbound and outbound testing for the team.
• Analyzed errors by running queries and produced reports for various departments.
• Managed Extol Mail Room on a daily basis for files that have been processed. Identified and analyzed the file errors and proposed resolutions to the team.
• Worked directly with Extol/ECM Implementation team to identify and review CRs and Ad-hocs; presented findings and status reports to the team.
• Configured and designed new client data. Reviewed BPOs, P&Ps and project plans and made changes and recommendations.
• Set up secure EDI connection according to DST rules and procedures, set up system to accept test files.
• Used Clarify to enter, track and manage ECM and Extol issues.
• Configured the code translation tables and 834 maps accordingly using Extol.

Confidential

Consultant 

Responsibilities:

• Gathered requirements via focus group discussions and personal interviews with providers.
• Designed requirements, specification documents, created test plans and test scripts and conducted system testing.
• Used Clarity to create reports, track project risks/issues, allocate roles to resources, etc.
• Prepared Use Case and task analysis for Providers to identify the new system’s processes for electronic invoicing.
• Developed literature to train providers on the new system. The training process was computer-based and instructor-led for all providers.
• Monitored and evaluated the new system’s functionality and post-implementation.
• Led meetings and discussions on strategies for a smooth transition to electronic invoicing from project inception to post-implementation.
• Conducted EDI set up process training for providers within the Virtual Gateway network.
• Worked with other team members and Executive Office of Health and Human Services staff to go through the process of deployment and maintenance of the system and EDI knowledge transfer.
• Requirements gathering from the client.
• Facilitate completion of trading partner agreements on behalf of medical providers and track providers readiness to "go-live" with HIPAA transactions.
• Conduct Companion Guide workshops for new providers.
• Participating in new Pilot program with selective Providers to test the Virtual Gateway and update Processes for HIPAA Compliancy.