SUMMARY

• IT Professional with over 9 years of experience with Healthcare Billing, Enrollment, Claims, Business Analysis, Requirement Gathering, Use Cases, Design, Change Control Process, Test Plans, Test Cases, User Acceptance Testing, User Manual and User Training.
• Implemented and performed all business analysis and testing activities in all phases of Software Development Life Cycle (SDLC).
• Gathered business requirements through JAD sessions and one - on-one interviews with the Business Stakeholders and tracked the requirements.
• Extensive knowledge of MMIS claims processing for Managed Care Organization (MCO) and Fee For Service (FFS)
• Extensive knowledge of Eligibility and Enrollment process, 834 EDI.
• Proficient in SQL queries and SAS. Worked on MA SQL server, XML and Web services. Proficiency in design and developing the ETL objects using Informatica Power center with various Transformations like Joiner, Aggregate, Expression, SQL, Lookup, Filter, Update Strategy, Stored Procedures, Router, Rank, normalizer transformations etc.
• Experience with HIPAA Compliance requirements and HL 7 standards and possess strong knowledge of healthcare X12 EDI (270/271, 276/277, 834,835, 837) transaction, ICD-9 and ICD 10.
• Prepared and submitted 837 I/P files processed in Edifecs to state reporting agencies.
• Worked in Edifecs to process X12 files as per requirements in Edifecs X-engine
• Experience with insurance administration systems included Policy Application, EDI Transactions, Eligibility, and Enrollment, Claim processing, Encounter Processing, Billing and Payments.
• Ability to define timelines for prioritizing work requests using tools such as MS Project.
• Ability to model business processes (BPM) in enterprise level projects using industry standard case tools.
• Sound knowledge of concepts like Gap Analysis, Risk Analysis, Impact Analysis, Data analysis, etc..
• Excellent writing skills in writing Business requirements document, Technical requirement documents, Design documents, USE Case Specifications, Functional Specifications, Systems Design Specification (SDS), Systems Requirements Specification (SRS)
• Expertise in Agile, RUP, SCRUM, Waterfall SDLC (Software Development Methodologies).
• Prepared Test Plans, High level Scenarios, and Test Cases from Requirement and Design documents.
• Prepared comprehensive and detailed Status, Defect and Test Summary reports.
• Escalation of problems & issues related to test environment with support team.
• Experience in Quality Center, TFS, JIRA (Bug Tracking Tool) for bug Project management and bug tracking application.

TECHNICAL SKILLS

UML: USECASE, Activity Diagram, Class Diagram, Sequence Diagram, Data Flow Diagram, Flow Charts

Programming Languages: SQL, SAS, PL/SQL, VB Script, C, C++, Cobol, XML.

Software Programs/Operating Systems: MS Word, Excel, MS Project, MS Visio, Windows NT/2000/XP, QTP, Quality Center, TFS, SOAP UI

Database: MS SQL Server, Oracle, DB2, IMS

Environment: Mainframe, ASP.NET, MS SQL Server 08, Web Service, SOA, IBM Curam

X12 EDI: 270/271, 834, 835, 837, 999, 277CA

PROFESSIONAL EXPERIENCE

Confidential

EDI Business Systems Analyst

Responsibilities:

• Accountable for receipt, distribution, tracking, and monitoring of all Medicare EDPS changes and updates as directed by the Centers for Medicare & Medicaid Services (CMS)
• Worked on RAPS and EDPS reconciliation change requests
• Extensively worked on 999 and 277CA response error correction
• Worked with data analysis team to identify pending encounters and reject codes
• Prepared various RFPs for various State projects
• Coordinated with CSSC to resolve discrepancies in responses and reports received from CMS
• Provided X12 structure guidance to avoid TA1/999 rejections
• Responsible for End to End validation and processing of encounters
• Functional coordination with the EDPS team to develop rejects management dashboards for Encounter Data Management in Medicare and Medicaid
• Validated all the incoming/Outgoing data from EDI 837 on Conduent web portal
• Provided assistance with weekly data extractions and imports utilizing SQL in IBM DB2
• Coordinated the testing effort for End-to-End Testing and User Acceptance Testing
• Provided X12 error resolutions using 837 companion and implementation guides
• Customize EDPS solution for various Health Plans based on individual customer requirement
• Reject Analysis of CMS 999s, 277CA and MAO-002 level errors and reports
• Worked closely with Management and cross functional teams to implement complex business solutions systematically.
• Prepare business cases, initiate, manage and deliver projects; develop detailed total cost of ownership including project cost estimates
• Proactively manage changes in project scope or schedule and assess their impact on budgets, business processes or other initiatives
• Presented change request cases to change control board for approval, provided impact analysis of the system and prepared technical documents to support change requests
• Prepared data mapping documents for enterprise data warehouse updates based on CMS and State Medicaid reporting requirements
• Drive effective business governance of projects and post implementation oversight of applications
• Work with business colleagues to develop and support strategies for business process improvements through information systems automation
• Validated and processed healthcare transactions across all channels in multiple formats in Edifecs.
• Worked on multiple projects using Edifecs SpecBuilder and MapBuilder.
• Worked on data profiling & various data quality rules development using Informatica Data Quality.
• Implemented Exception Handling Mappings by using Data Quality, data validation by using Informatica Analyst.

Confidential, Chicago

Business analyst

Responsibilities:

• I was working with Illinois Medicaid and New Mexico Medicaid market to make HCSC compliance with state Medicaid agency.
• Prepared Business Requirement Documents based on state guidance.
• Lead the effort of migrating eligibility and enrollment system from legacy system to Facets.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather Business requirements.
• Conducted controlled brainstorming sessions with project focus groups for collecting high-level business requirements.
• Conducted several Requirement Gathering Sessions for gaining detailed requirements and finalizing Business Requirement Document (BRD).
• Involved in data mapping, field mapping of the data elements responsible for the BRD.
• Performed GAP analysis of business rules, business and system process flows.
• Worked on multiple projects simultaneously.
• Achieved expertise in Facets Systems of claims and Members both front end and back end.
• Worked on Prior Authorization, Claims Systems, member enrollment and eligibility, TPL, PPL, and Customer Service Requests.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Worked on to be compliant with NJMMIS for Encounter submission.
• Developed robust encounter reconciliation process for monthly reconciliation.
• Developed various reports to monitor claims inventory, dollar over payment to providers, member’s fall off report, TPL and PPL payment reports and various ad hoc reports as requested.
• Worked on updating member prior authorization system
• Developed different reconciliation reports to provide end to end data analysis.
• Validated various gaps between MMIS and Trizetto system in terms of data and provided guidance to Trizetto to close these gaps.
• Worked closely with Government Affairs, regulators and third parties to identify potential impact of new legislation and regulations on encounter data reporting.
• Involved in developing various EDI file mapping using Edifecs Mapbuilder.
• Monitored inbound and outbound files using Edifecs for claims to encounter conversion.
• Worked with Informatica Data Quality toolkit, Analysis, data cleansing, data matching, data conversion, exception handling, and reporting and monitoring capability
• Responsible for validating Target data after applying different Informatica Transformations on the Source Data.

Confidential - New York, NY

Business system Analyst

Responsibilities:

• Developed project schedules, requirements and preliminary design for environment applications
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements
• Involved in validation of Claims Institutional & Professional ThroughFacets
• Facilitate various Vendor & Provider calls and takemeeting minutes, Create Documents, Process Flows, Presentations
• End to End Claims Adjudication Validation & Analysis through TrizettoFACETS Claims, Billing, Member, Provider and Utilization Management Module
• Conducted controlled brainstorming sessions with project focus groups for collecting high-level business requirements
• Conducted several Requirement Gathering Sessions for gaining detailed requirements and finalizing Business Requirement Document (BRD)
• Involved in data mapping, field mapping of the data elements responsible for the BRD
• Performed GAP analysis of business rules, business and system process flows
• Worked on Prior Authorization, Claims Systems, member enrollment and eligibility, and Customer Service Requests
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Claims and Encounters
• Provided analytical support utilizing MS SQL Server to cleanse claims data for EDI encounter submissions and ad hoc data analysis
• Prepared monthly encounter error reports to monitor encounter rejections and provide a fix to Trizetto with CMS guidelines
• Performed system analysis, trend analysis, data analysis, and historical claim assessments
• Developed various reconciliation reports to provide end to end data analysis
• Conducted UAT for various initiatives and enhancements

Confidential | Bronx, NY

Business Analyst

Responsibilities:

• Prepared design documentation - liaising with IT Technical staff to complete development
• Used various requirement elicitation techniques such as document analysis, interviews, use cases and surveys/questionnaires
• Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using Rational Rose / MS Visio / BPMN facilitating clear understanding of the business processes
• Interacted with Claim Adjudication, Claim Reimbursement and Billing SME’s to finalize business requirement
• Translated the requirements to the development team and provided guidance with issues related to business requirements