SUMMARY

• Over 8+ years of Experience as Business Analyst in Healthcare include understanding of Business Requirement Gathering,Business Analysis, Joint Application.
• Excellent knowledge in Health Insurance, Health Insurance Exchange (HIX), Asset Management, PBM, Data Warehousing, and Human Health Services (HHS) environment.
• Having extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, System, Medicare and Medicaid, CMS Compliances/Regulations.
• A Data Warehouse developer, Data modeler, Data Analyst with more than 5 years of experience in all phases of Software development life cycle (SDLC) including System Analysis, Design, Data Modeling.
• Profound knowledge of EDI X12 standards in healthcare insurance.
• Extensive experience as Business Analyst in the Healthcare Industry with expertise in EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare and Medicaid.
• Worked extensively on creating reports and dashboard in Power BI from different databases & sources.
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
• Gained extensive experience in designing/modifying the CICS screens for various areas such as Enrolment, Billing, Provider Record and Reimbursement Status in MMIS. Enrolment, Billing, Provider Record and Reimbursement Status in MMIS.
• Consulted with application development business analysts to translate business requirements into data design requirements used for driving innovative data designs that meet business objectives.
• Extensively worked on creation of Narrative Use Cases, Data Flow Diagrams, Activity Diagrams, Work Flow Diagrams and Sequence Diagrams to define the business Process Model and Data Process Model using UML Rational tools/ MS Visio.
• Adequate knowledge in Health Administration - Claim’s processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Medicare, Medicaid, CDHP (consumer driven health plans).
• Excellent understanding of business requirements, functional requirements, non-functional requirements, technical requirements, and business process flows.
• Writing complex technical specifications detailing data transformations, business rules and workflows.
• Designing distributed systems including defining interfaces between applications.
• Flexible, innovative and able to thrive in a fast paced, growth-oriented and time-critical environment.
• Extensively worked on creation of Narrative Use Cases, Data Flow Diagrams, Activity Diagrams, Work Flow Diagrams and Sequence Diagrams to define the business Process Model and Data Process Model using UML Rational tools/ MS Visio.
• Extensive Experience in Functional, Integration, Regression, User Acceptance UAT, System. technical proficiency in healthcare applications like GE/IDX, EPIC PM/EMR, Siemens, NextGen, Athena, EMDEON, Clinical Systems, HL7 interfaces and other areas of healthcare industry.
• Utilized corporation developed Agile SDLC methodology.
• Designed and Developed Complex Active reports and Dashboards with different data visualizations using Tableau desktop on customer data.
• Industrial experience includes Healthcare HIPAA and EDI, EHR clinical Systems.
• Expertise in creating Data flow diagrams, Entity Relation diagrams, Gap Analysis, Developing Business Process Re-Engineering and Process Modeling using MS Visio.
• Experience in data analysis, data visualization using Tableau/Microsoft Power BI, model building with machine learning algorithms for prediction and forecasting using data (historical or time series with regression techniques), using statistical/econometric tools like SAS and R, data mining using python, SQL, Hadoop, Spark, Hive, etc.
• In-depth knowledge of payer operations including claims, enrollment, eligibility, underwriting.
• Good knowledge on performing requirement management using JIRA.
• Experience in facilitating Joint Requirement Planning (JRP)sessions with business user groups, conducting Joint Application Development (JAD)sessions with IT groups and conflict management with project team members.
• Experience in performing Gap analysis, Scope analysis, Risk analysis and Impact analysis to define boundaries, identify issues, minimize costs and optimize the solutions.
• Sound knowledge of Affordable Care Act (ACA), Consolidated Omni bus Budget Reconciliation Act (COBRA).
• Analyzed Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
• Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 & 271HIPAA EDI Transactions using MS Word, MS Excel.
• Providing live training and creating training manuals on product application and different tools like Tableau, JIRA, ALM and Hadoop Hive.

TECHNICAL SKILLS

Healthcare Compliance: HIPAA (Health Insurance Portability and Accountability Act), HITECH (Health Information technology for Economic and Clinical Health) Act, (ACA) Affordable Care Act, Medicare & Medicaid, MACRA (Medicare Access & CHIP (Children’s Health Insurance Program) Reauthorization Act.

Business Skills: Business Process Analysis, Business Process Improvement, Use Case Modeling, BPMN, JAD sessions, Risk Analysis, PERT Analysis, Requirements Workshops, GAP analysis, SWOT Analysis, Document Analysis, Impact Analysis, Sensitivity Analysis, Cost Benefit Analysis, Data Analysis, Data Profiling and Data Correlation Analysis.

Business Modelling Tools: MS Visio, Mockup Screens.

Reporting/BI: Tableau, Microsoft Power BI.

Project Management Tools: MS Project, MS Visio, MS SharePoint, MS Excel, MS Outlook, MS PowerPoint, HP Application Lifecycle Management (ALM), JIRA, Confluence.

Office Tools: Tableau, MS Word, MS Excel, MS PowerPoint, MS SharePoint 2013, MS Project, MS Visio

PROFESSIONAL EXPERIENCE

Confidential

Sr. Healthcare Business Analyst

Responsibilities:

• Assisted JAD sessions to identify thebusinessflows and determine whether any current or proposed systems in SOA are impacted by the EDI X12 Transaction, XML, XSLT, Code set and Identifier aspects of HIPAA.
• Involved in GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Managed company's EDI catalog for prospective EDI customers and gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Implemented new services and programs via MMIS for the Medicaid program by directly interfacing with the customer and the system engineers on a regular basis.
• Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare and Florida Medicaid.
• Worked with Facets software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPPA transactions and facilitate the administration of HIPAA privacy rights.
• Responsible for the regulatory management process for the services provided by the pharmacy.
• Reviewed basic SQL queries and edited inner, left, and right joins in Tableau Desktop by connecting live/dynamic and static datasets.
• Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.
• Use HP Quality Center to house all test documentation and report/track all issues and defects Defect Management.
• Assisted and written System Requirements Documents SRD, including Functional and Non-Functional requirements.
• Gathered business requirements through interviews, surveys, prototyping and observing from account managers, finance manager, and independent advisors and got an accurate understanding of their needs.
• Assisting users with questions and issues using Tableau. Working with various infrastructure teams and Tableau support team to help improve dashboard response time.
• FHIR messaging, structure and expertise in building complex event based real time interface.
• Created risk and quality reporting using combination of Power BI and SQL.
• Performed testing for Medicare, Medicaid and claims for Medicaid Management Information System (MMIS).
• Advanced understanding of Oracle general ledger software and Hyperion Financial Management software.
• Developed and maintained understanding of customer workflows and business needs to support.
• Proficient in industry standard requirements gathering and modeling techniques to understand and communicate the needs of the product's users.
• Experience Data Analytics, BI products, Power BI, Tableau and several analytics tools.
• Utilized knowledge of SQL Programming to author over 20 Queries in the Management Dashboard.
• Skilled in gathering business and application requirements, Business Processes, identifying risks, impact analysis, UML modelling, and Sequence and Activity Diagrams using Rational Rose and Microsoft Visio in Clinical and Health Information Management (HIM) processes.
• Explored data in a variety of ways and across multiple visualizations using Power BI. Strategic expertise in design of experiments data collection, analysis, and visualization.
• Created 837 (P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837 (P, I, D), 834, 835, 270, and 271.
• Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.
• Documented ICD9 to ICD 10 mappings one to one/one to Many according to the GEM files from CMS with the functional and structural changes related to the conversion.
• Involved in Able to understand and implement Processing ICD-9 ICD-10 and Worked on EDI transactions: X12,835, and 837 P.I to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.

Confidential, Thousand Oaks, CA

Sr. Healthcare Business Analyst

Responsibilities:

• Used tools such as MS Visio, Rational Rose to define business use cases, activity diagrams, state and sequence diagrams.
• Created and maintained System Architecture Document (SAD) Requirement Traceability Matrix (RTM) and created document management tracker to upload deliverables on timely manner for CMS (Centers for Medicaid and Medicare Services).
• Experienced in software development life cycle such as, Agile-SCRUM methodologies, Business Analysis and Modelling.
• Developed SQL scripts for verification of data at extraction phase to ensure, transformation phase and loading phase of the data to ensure correctness of the data and also verifying the ETL mapping rules.
• Involved in testing HIPAA EDI X12 transactions & Code Sets Standards like (820-Premium Payment for enrolled health plan members, 834-Enrollment /Dis-enrollment to a health plan, 837- Health Care Claims and 278 Authorizations.)
• Excellent knowledge in Data Analysis, Data Validation, Data Cleansing, Data Verification and identifying data mismatch.
• Created parameters, Calculated fields and filters in Tableau to represent correct analytical data.
• Designed Power BI data visualization utilizing cross tabs, maps, scatter plots, pie, bar and density charts.
• Developed Tableau dashboards, Crystal reports and SSRS BI reports for data insights and to monitor the health of data load activities.
• Worked on Business process documentation to ensure HIPAA compliance and EHR conversion was secure.
• Utilized Teradata SQL to extract, aggregate, and analyze large complex data sets.
• Analyzed proposal requirements, work with business development and subject matter experts develop outlines and ensure the proposal comply with RFP requirements.
• Assisted in designing policies and procedures to protect the privacy of Electronic Protected Health Information to ensure data integrity as per HIPAA guidelines.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases.
• Used the requirement attributes (priority, effort, and risk) as the basis for negotiating the inclusion of the requirement, to manage the scope of the system efficiently.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data Configured the Data mapping between Oracle and SQL Server.
• Trained the team on JIRA tool for Agile/ Scrum Methodologies and Worked with ETL groups and Acquisition team and Data analyst for understating mappings for dimensions and facts.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Collaborated with stakeholders to develop business requirements and convert those requirements to technical specifications in support of reporting and software development. Responsible for documentation compliance with CMS XLC (Expedited Life Cycle).
• Created work flow diagrams using MS Visio, Project, PowerPoint.
• Assisted business user during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility and billing essential.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery. system Validate and developed meta data for all developed reports in Microsoft power BI desktop.

Confidential, Philadelphia, PA

Healthcare Business Analyst

Responsibilities:

• Created various reports such as billing payment reports, Billing Grouping Payment and discount reports & Worked on false positives claims by analyzing rejected claims and evaluated Medicare requirements and benefits in Medicare Health Plans for member enrolment and management.
• Performed Analysis on Data mapping between different data models & Evaluated Medicare requirements and benefits in Medicare Health Plans for member enrollment and management.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Designed and implemented basic SQL queries for testing and report/data validation.
• Preparing BRD, Business Cases, and presentation to the clients, Business Re-engineering proposals.
• Involved in TriZetto Facets System implementation, Electronic Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 835 and proprietary format files and Reports development.
• Worked in RUP using Rational Requisite Pro. Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Developed a vision plan that defined the primary goals and objectives of the project. Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagrams so that developers and other stake holders can understand the business process by using UML.
• Workflow documentation and comprehensive training to the healthcare clients.
• Analysed corporate healthcare business processes to develop customized solutions. performed unit testing and system testing on Aetna claims.
• Worked on enhancement & rescoping of system requirements suited to operate on the new platform.
• Proficiency with Office applications (Word, Excel, PowerPoint, and Visio and Project Management Software), and Atlassian (JIRA, and Confluence).
• Performed Defect Tracking and Project Tracking using Jira - Change Notification Request (CNR).
• Ability to analyze engineering product support issues described within a bug-tracking system (JIRA) and provide guidance to other Client Services members in an advisory capacity, focusing on the quick resolution of the production issue and using this as a training opportunity for other team members.
• Expertise in the EPIC Medical software application (EMR, EHR) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Project plan, and risk analysis.
• Research and Implementation of Web Portal and Content Management Systems.
• Consulting with other departments on the management of content and design of pages.
• Articulated UML through Use Cases, use case document by specifying actors, normal flow, sub flow, alternative flows for each and every use case.
• Complying with the consistent development and maintenance of the healthcare industry databases, health care insurance and health care industry related aspects with adherence to HIPAA compliances.
• Utilization of BPM, as-Is and To-Be modelling processes.

Confidential, TX

Healthcare Business Analyst

Responsibilities:

• Developed a logical Integration model detailing the flow of information through the various components, including definition of external and internal message contents.
• Participated in Business Analysis, talking to business Users and determining the entities and attributes for Data Model.
• Conducted JAD sessions with various SMEs and users to analyze and discuss project scope, to identify thebusinessflows and determine whether any current or proposed systems are impacted by the new development efforts.
• Prepared test scripts for the successful execution and testing of Inbound IVR, Vendor supported outbound IVR and CCA Care Bridge.
• Defined and presented various solutions and artifacts to the State of Massachusetts to reduce the number of VC1 notices to the applicant when address verification fail.
• Worked with plan management to upload various SERFF templates into the web portal.
• Executed test cases manually. Compare and analyze actual with expected results and report all deviations to the appropriate individual(s) for resolution.
• Involved in creating and responding to action items including generating reports that have been predefined in crystal reports.
• Performed Extraction, Transformation and Loading (ETL) using Informatica power center.
• Adopt enhanced knowledge of industries standard SDLC methodologies and having extensive experience working on RAD and RUP including Joint application development (JAD), Joint requirement planning (JRP).
• Performed Backend testing by using PL/SQL queries to test the integrity of the application was in regular contact with Business partners on the status of issues, action plans and timeframe for resolution throughout the development cycle.
• Strong Knowledge on Business Data Enterprise Planning - HL7 v2.4, HAPI (HL7 Open Source), CMS EFT/EDI Gentran Integrate Suite (GIS)/Connect: Direct (MDCN), Sterling Secure File Transfer Protocol, WebSphere SOA, WebSphere MQ, WebSphere Tivoli, WebSphere Message Broker and IACS (single sign-on).
• Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes, Claims Process, Health information Exchange (HIE), Electronic Health Record (EHR) and Electronic Medical Record (EMR).
• Developing a single application to process data from multiple integration points, convert the data for reporting purposes and feed data into mainframe system to be compliant to reporting requirements.
• Identified bugs during the test phase and reported them using HP Quality Center.
• Functional Knowledge of Medicaid Management Information System MMIS.
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Created and maintained source-to-target Data ping and Data conversion spread sheet.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
• Worked on analyzing business requirement at all stages of Software development of life cycle SDLC.
• Created approach to standardize Excel Reporting using SQL in the Management Dashboard.
• Wrote transformations for data conversions into required form based on the client requirement using Teradata ETL processes.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology. Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.