SUMMARY

• Around 7+ years’ experience as Business / Data Analyst in directing cross - functional teams of technical experts to analyze systems & processes and implement infrastructure improvements.
• General experience includes Business Process Analysis, Business Modeling, Business Intelligence, User Acceptance Testing (UAT) and Implementation. Expert in developing Business and System Requirements, Design Documents, working with requirements traceability matrix
• Extensive experience in JAD and JRD. Health Insurance Background - Specifically related to collecting requirements, documenting and representing the business, Use Cases, Business process improvements, etc.
• Experience in Medicaid Management Information System (MMIS).
• Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB)
• Strong experience in SDLC and RUP Business Modeling process. Design and review of various documents including the Software Requirement specifications (SRS), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM) and testing documents. Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Agile and Scrum. Skills include defining Project Scope, Business Process Analysis, Business Process Reengineering, Requirements Gathering, Data and Process Modeling. Strong knowledge of managed care payer requirements and procedures.
• Expertise in understanding the business needs, defining a creative and useful software solution to the management, implementing and training the application to the user community. Strong project management skills including planning, scheduling, monitoring and budgeting with experience in requirement gathering, gap analysis, risk analysis, effort estimation etc.
• Full knowledge of applicationinteroperabilityconfigurations and managed the implementation tasks of HIE clinical applications.
• Well versed in gap analysis in changing old MMIS mixed up with testing new MMIS.
• Experience in Managing client relationships and assisted Account Manager with administrative processes, client participant outreach, order management, client-billing administration, and participantdataanalysisand research
• Operational experience in HealthCare Provider &PayerIndustry-EPIC Implementation, Membership, Eligibility, Claims, Billing and Reimbursement.
• Extensive experience with project leadership, business analysis,datamanagementand business and system development. Pursuing leadership roles that focus on process improvement and innovation.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding andHL7.
• Good Knowledge of HIPAA Compliance Lifecycle, HIPAA Insurance Regulations and Claims Processing.
• Expertise in understanding HIPAA 835, 834, 820, 270, 271, 276, 277, and 278, EDI, Privacy, Security, and Medicaid.
• Worked on implementing HIPAA 4010 and HIPAA 5010 transaction set rules.
• Expertise in Requirement Analysis, requirement modeling using Unified Modeling Language (UML) and Object Oriented Analysis.
• Hands on experience in Project Management while assisting Senior Project Manager.
• Experience in writing test plans, reviewing test cases and mentoring QA teams.
• In-depth knowledge of conducting User Acceptance Test (UAT), data quality checks using SQL, gap analysis and Requirement Traceability.
• Experience in Functionality Testing, User Acceptance Testing, Database Testing, Regression testing and Risk Based Testing
• Extensive experience inverification, validation (cross-functional testing) and SDLC Process
• Excellent working experience with SQL Server.
• Ability to manage multiple projects concurrently.

TECHNICAL SKILLS

Operating Systems: Windows, Unix, Linux

Software Methodologies: SDLC, SCRUM, Agile, Waterfall Model, Rational Unified Process (RUP), Rapid Application Development (RAD), Object Oriented Design & Analysis, ER Modeling and Database Design

Databases: MS Access, Automated Enrollment, Oracle (SQL), SQL Server, Oracle, DB2, IBM AIX

Programming Languages: HTML, Java, J2EE, C/C++, PLSQL

Microsoft Office Suite: MS Project, MS Word, MS Excel, PowerPoint, MS Visio, MS SharePoint, MS Office

Reporting tools: Business Objects, Crystal Reports, OBIEE

Business Modeling Tools: Rational Rose, Clear-Quest, Requisite-Pro and Clear-Case

PROFESSIONAL EXPERIENCE

Business Analyst

Responsibilities:

• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Gathered high-level requirement for all the external projects in a release.
• Performed the requirement analysis, impact analysis and documented the requirements.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• 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.
• Performed Analysis on Data mapping between different data models.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.
• Created ICD-9-CM/ICD-10-PCS comparison document and dealt with DRGs.shift through CMS files.
• 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
• 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
• Executed the test cases and test scenarios using HP Quality center QC .
• As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.
• As Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming session, daily scrums product demos, sprint reviews and sprint retrospectives.
• Prepared Business Requirement Documents BRD's after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.
• Created various reports such as billing payment reports, Billing Grouping Payment and discount reports
• Use HP Quality Center to house all test documentation and report/track all issues and defects Defect Management

Confidential, Detroit, MI

Business/Data Analyst

Responsibilities:

• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders. Analyzed user requirement documents (URD), Systems requirement specification document (SRS) and prepared System test plan by dividing the application into manageable units.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Responsible for envisioning and architecting the enterprise-level Identity and Access Management Infrastructure initiative, addressing the need for compliance with the HIPAA regulations pertaining to security and privacy of patient health information. Function testing with clearinghouses and direct payers and added storied into Rally.
• Compiled and reviewed medical charts based on ICD-9 codes from progress notes, hospital stays, ER visits, and consults and entered information into system for MedicareRiskAdjustment studies.
• Worked on Payment Integrity, policy maintenance, provider monitoring, quality care dashboards, healthcare claim analytics and fraud Support.
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process. Document and communicate changes throughout the user organization, supporting Information System Change Management (ISCM) and compliance. Utilized Agile/ SCRUM and PMI methodologies to monitor steer and develop project objectives. Responsible for executing User Interface Testing, System Testing, Data Quality Testing on the configuration design and prototypes.
• Analyze healthcare provider files for potentialriskreview and obtain malpractice coverage for all contracted providers thru appropriate entity.
• Performs weeklyDataAnalysisfor Medical Review management to ensure adjudicated claims are reimbursed both accurately and appropriately, per Medicare Guidelines
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team
• Conducted user interviews and documented business and functional requirements. Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data.
• Developed and Enhanced Electronic claims processing screens and programs for Online editing and Claim entry in CICS, working with a developer
• Involved in mapping data from different EDI files onto database using different routing transformations.
• Analyzed the root cause analysis for batch job failures and online application failures and take the appropriate action to avoid the batch delays.
• Defined, developed specs for federal reporting specific to Medicare Advantage. Contributed to software process-reengineering efforts aimed at evolving previous software development practices to adopt Lean/Agile and Scrum practices.
• Employed Rational Clear Quest for effective Change Management (Requirements Creep) and bug tracking during the testing lifecycle.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Documented and assisted in the implementation of ITIL business processes: CMDB, Service Desk, Incident Management, and Problem Management. CreatedProcess Flowdiagrams, Use case diagrams (UML) using MS-Visio.
• Managing overall testing process and project to production change management life-cycle.
• Participated in preparation of root cause analysis (RCA) documents
• Selected as core team member tasked with developing and delivering Disaster and Incident Management Exercises at client sites, conferences and workshops. Preparing System Test Cases from functional and technical requirement and Use case documents and performing System Testing. Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.

Confidential -Wichita, KS

Business Analyst

Responsibilities:

• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Gathered high-level requirement for all the external projects in a release.
• Performed the requirement analysis, impact analysis and documented the requirements.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• 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.
• Performed Analysis on Data mapping between different data models.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.
• Created ICD-9-CM/ICD-10-PCS comparison document and dealt with DRGs.shift through CMS files.
• 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
• 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
• Executed the test cases and test scenarios using HP Quality center QC.
• As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.
• As Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming session, daily scrums product demos, sprint reviews and sprint retrospectives.
• Prepared Business Requirement Documents BRD's after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.
• Created various reports such as billing payment reports, Billing Grouping Payment and discount reports
• Use HP Quality Center to house all test documentation and report/track all issues and defects Defect Management

Confidential, Deerfield, IL

Business Analyst

Responsibilities:

• Participated in user meetings, gathered Business requirements & specifications for the Data-warehouse design. Created Systems & Functional Requirement Document (SRD) and (FRD) and Physical and Logical Data models for healthcare Claims process/Membership from legacy and unstructured data sources. Involved in analyzing the claims on basis of Primary and Secondary Payers and performed Medicare subsidy eligibility check for employee group plans. Led and conducted JAD / JAR sessions for requirements gathering, analysis and design of the system.
• Established a business Analysis methodology around the SDLC, helped to develop use cases, project plans and manage scope.
• Created and updated user and system documentations fordatamanagementand records retention processes.
• Conducts TPL and WC claims investigations and directs outside vendor and /or internal team to validate, make collection calls, letters for identified overpayments and oversee the recovery process
• Interacted with Business Unit members for gathering data, information and requirements related to enhancing pharmacy claims and Medical, Lab and Radiology Report for HL7, and CCDA.
• Involved in the meeting with Business Process Owners, SME (Subject Matter Experts) and store users for Requirement gathering in Definition Stage.
• Gathered client specific systems requirements and translated it in a proper manner to the developers, and ensured that these requirements were fully tested and implemented accordingly for each production cycle by creating Traceability Matrix using Requisite Pro. Responsible for creating systems work flows and processes using Rational Rose for creating management reports based on the analysis. Worked with Claims, enrollment, eligibility verification for members and providers, benefits setup, and backend payment cycle in facets. Understood core processes of the departments to provide input on re-engineering or Streamline opportunities.
• Used MMIS - Medicaid Management Information System for Insurance Claims Filing and patient information using MITA - Medicaid Information Technology Architecture as a platform.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System (MMIS) reports.
• Manage Scope and change throughout the SDLC process of the product. Responsible to write BRD’s containing specifications related to HIPPA 0/271, 276/277) for Medicaid and Medicare Payers and other payers.
• Experience in SQL ad-hoc queries to extractdatafrom various database fordataanalysisand generating reports per the format specified Subjects Matter Experts (SME's).
• Responsible for writing Functional Requirement Specifications (FRS). Assisted the Project Manager to develop both high-level and detailed application architecture to meet user requests and business needs. Created workflow diagrams to better demonstrate the processes adopted in the EDI group and accounting groups of the company.
• Worked on project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations.
• Created new and modified existing reports using the Actuate Developer Workbench and integrated it with Siebel.
• Conducted the FRS reviews and walkthroughs with designers, developers and stakeholders.
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams/State Chart Diagrams (UML).
• Created Data Stage jobs to extract, transform and load data into data warehouses from various sources like relational databases, application systems, temp tables, flat files etc.
• Prepared Screenshots and web layouts for the application
• Prepared Test Strategy, Test Plan, test report and Gap Report
• Performed UAT based on Requirements Document and prepared the Test Cases using Quality Center.
• Maintained Traceability Matrix in Excel.