We provide IT Staff Augmentation Services!

Sr. Business/edi Analyst Resume Profile



  • 9 years of experience as a Business/EDI Analyst with strong analytical and problem solving skills, maintain excellent interpersonal communication while working on long, complex and tedious assignments.
  • Extensive knowledge of Software Development Life Cycle SDLC including Enterprise Analysis, Requirements Planning, Elicitation, Analysis, Communication, Solution Assessment and Validation of Projects.
  • Worked on various methodologies such as Agile Software Development, Rapid Application Development RAD , Joint Application Design JAD and Prototyping.
  • Create, Review and Analysis of Business Requirement Documents BRDs , Functional Specification Documents FSDs , Use Case Documents, Business Rules Spreadsheets BRS and Standard Operating Procedures SOPs .
  • Extensive knowledge of Medical Management Information Systems MMIS , Medicare, Medicaid and National Provider Identification NPI .
  • Excellent knowledge of Health Insurance Portability Accountability Act HIPAA standards, Electronic Data Interchange EDI , Implementation of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
  • HIPAA Transactions mapping experience and in-depth knowledge of HIPAA framework. Strong experience transacting with Healthcare EDI standards - ANSI X12 v 5010/4010 834, 835/837, 270/271, 276/277 BPML and HR-XML formats
  • Excellent knowledge of Medicare Part A, B, C and D and Medicaid Health Insurance Policies like CHIP, Personal Injury Protection PIP insurance, billing experience in life and disability in health plans etc.
  • Hands on experience with UI, White Box, Black Box, Unit, Functional, Integration, Back End and System Level Load and Stress Testing for web-based client server applications.
  • Architecture and design work for specific EDI Mapping Projects, Mapping and implementing message translations for connecting trading partners to each other and to the applications
  • Document Interchange Control Document ICD and Exchange Companion Guide for 837/835, 834 and 820.
  • Create Master Mapping Document for Sterling B2B Integrator mapping of 834 and 820 data fields with CMS, CG, Siebal and OneGate application fields .
  • Worked with prospective trading partners to determine data processing and EDI operation requirements, from this, authored technical specifications to support findings
  • Web service testing for ANSI X12 837/835, 834 and 820 Messages, Send/Receive 999 / TA1
  • Create 834 and 820 specification documents for Coding and Development


Methodology: SDLC, RUP, Agile, Agile PLM, OOAD and Waterfall.

Languages: Oracle, PL/SQL, HTML BPML, XML, .NET, JAVA, C

Management Tools: CaliberRM, Rational Rose, Requisite Pro, Clear Quest, Clear Case, Serena Team Track and MS Visio.

Testing Tools: HP Quality Center, Mantis, Win Runner, Load Runner, TOAD and SOAPUI/WSDL

Data Modeling Tools: ERwin, Informatica 7.1.1/8/9, Hyperion.

Database: Oracle 8i/9i/10g, DB2, MS SQL Server.

Operating Systems: UNIX/Linux, Windows 95/2000/NT/XP and MS-DOS.

Microsoft tools: MS Office 2003, 2007, 2010 Word, Excel, Power Point, Outlook , MS SharePoint, MS Visio, MS Project and MS FrontPage.


Sr. Business/EDI Analyst

Confidential is the most diversified health care company in the Confidential and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone. Recently Massachusetts has hired confidential unit and an insurance executive to fix its problem-plagued health exchange, which is still not working properly, more than four months after it launched. I am working as Business/EDI Analyst, dedicated to handle enrollment 834 and payment 820 files across different systems.


  • Analyzed and Design Health plan Enrollment and Maintenance ANSI X12 834 and Premium Payment ANSI X12 820 file specifications under HIPAA framework for ACA Affordable Care Act .
  • Prepared implementation plan and negotiated agreement on EDI file specifications with Trading Partners and vendors in accordance with HIPAA guidelines.
  • Interfaced with technical staff, trading partners, Clearinghouses and internal staff including programmers on all HIPAA related information and changes.
  • Created Test Case and Test Scenario based on X12 834/820 B2B Integration Functional Testing.
  • Work on Production Environment Revert to Draft R2D process and used SOAPUI tool for Web-service Testing Send X12 834/820 Messages, Send/Receive 999 / TA1's along with maintenance of the file using Oracle Spec builder 6.6.1 powered by Edifecs.
  • Design process flow chart of EDI Transactions Portal --> HIX --> Carriers using MS Visio 2010.
  • Identified/anticipated issues with HR-XML/ANSI File feed and business rules. Documented the event, articulate and demonstrate the problems to facilitate resolution.
  • Worked with trading partners to implement and troubleshoot connectivity to EDI systems that included Secure FTP, FTP with PGP encryption for batch transactions and Web services for real time transactions.
  • Reviewed errors and EDI transaction reports and analyzed information for trends.
  • Created Process Flow Charts, Business Requirements Documents, and Functional Specification Documents for Revert to Draft R2D process.
  • Developed Test Plan and Test cases based on the Use cases and Functional specifications and also performed User Acceptance Testing UAT of the functionality of the application by inserting varying data on different test runs.


Sr. Business/EDI Analyst

Confidential is Partner with 175 global P C, life and commercial health insurers plus agencies and brokers, provides end-to-end IT and business process management services along with industry-leading software solutions.Vermont has contracted with global IT firm CGI to build the infrastructure for Vermont Health Connect, the state's health insurance exchange.


  • Teamed up with Senior Managers in managing System EDI and data processing requirements, System design and Architecture, develop and test EDI Portal Redesign applications and transactions.
  • Worked on EDI Portal from its inception to completion and then support it.
  • Interfaced with technical staff, trading partners and internal staff including programmers on all Eligibility/enrollment related information and changes.
  • Developed and implemented testing scenarios in conjunction with Business Requirements.
  • Involved in developing Business Functions/rules and regression test cases.
  • Performed EDI technical and operational customer support to trading partners and customers related to their operational and business needs, requirements and issues
  • Monitored EDI systems to ensure smooth processing of inbound and outbound transactions and provided technical support when needed.
  • Teamed up with various e-Business areas in their overall efforts to make EDI infrastructure X12 5010 compliant and got involved in Gap/Risk Analysis.
  • Worked on design and Analysis of HIPAA EDI X12 834, 820, 999 and TA1 Transactions, Performed web service Testing Send X12 834/820 Messages, Send/Receive 999 / TA1 .
  • Documented Interchange Control Document ICD and Exchange Companion Guide for 834/820 along with process flow of EDI transactions using Visio and Power point.
  • Create Master Mapping Document mapping of 834 and 820 data fields with CMS, CG, Siebal and One Gate application fields along with Technical Specification Document TSD for Coding and Development.
  • Develop EDI X12 transactions Oracle XSD, ECS and XML files using ORACLE Spec Builder and SOA B2B Integrator.
  • Very good understanding of ORACLE Health Care Adapters HIPAA EDI X12 834 / 820 .
  • Developed Test Plan and Test cases based on the Use cases and Functional specifications and also performed User Acceptance Testing UAT of the functionality of the application by inserting varying data on different test runs.

Sr. Business Analyst

Confidential has provided carve-out prescription benefit programs founded on the philosophy of integrity, Innovation and a clients first approach. Confidential is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. They are specializing in delivering progressive benefit programs to private and public sector organizations with a 100 to 5,000 membership.Worked on the project call Medicare Part - D Prescription Drugs Plan which includes Members and their enrollment eligibility group and individual , Coordination of Benefit COB , Billing and Payment assignments.


  • Serve as an active member of PDP team, interacting with developers, business users and subject matter experts SME to analyze and configure PBM Web-Portal functionality based on Business Requirement.
  • Gather and analyze requirements for Member eligibility Group and Individual , Coordination of Benefit COB , Billing and Payment to develop PBM Prescription Benefit Management .
  • Worked on Configuration and integration of Member Enrollment, CMS, Drugs, and Plans, Pharmacy, Claims, Clinical and AR/AP member activity Management sections.
  • Create and Analysis of Data Transaction Reply Report DTRR , Schedule meetings with Business team and Developers on project status. Try to make sure that all three releases A, B and C follows deadline.
  • Conduct JAD sessions with Business Team and Developers to discuss the Code implementation and configuration of Web Portals.
  • Perform Regression testing on both internets PBF and Intranet PBM Web-portals to check compatibility between two code releases.
  • Create and Maintain Requirements, Test Cases and Test Plans, Perform Agile development methodology on development process we are going through.
  • Coordinate with BSA to analyze User requirements, Current operational procedures, functional specifications and User data processing.
  • Run Batch eligibility query BEQ files check Transaction Code TC and Transaction Reply Code TRC to make sure Member enrollment has been completed.
  • Perform object-oriented analysis, discuss finding with Developers to make sure both teams are on same page during this development process.
  • Attend walk through meetings for Requirements Review, Analysis and Approval of them.
  • Worked on System and Integration testing and used Mantis Bug tracking tool to report and monitor issues in code, Perform Manual Testing to make sure issues have been fixed.
  • Deal with CMS Member Pending Enrollment on daily basis like Low income Part LIP -D, Late enrollment penalty LEP etc.
  • PBM incorporate complete Member Enrollment and Eligibility check, Drugs Prescription, Plan design, Claim adjudication and Verification, Call chain, Rx enquiry, Clinical requests handling etc.
  • Worked on all the phases of Medicare Part-D claims, for example Deductibles, initial coverage, gap and catastrophic etc.
  • Developed Traceability Matrix including BRD and FRD to track down different defects related to Member enrollment eligibility, Claims adjudication, Clinical request from members.

Environment: MS Office MS Word, MS Excel, MS PowerPoint, MS Visio Lotus Notes, Mantis, Rational Requisite Pro, Sql, Java scripts, JSP

Business/EDI Analyst

Confidential is the one of the best US Health service provider currently engaged with confidential global health Service Company to support the implementation of HIPAA 5010 system enhancements. This project came into existence when Confidential rejected substantial amount of past Medicaid/Medicare Encounters on 837P, 837I and 837D EDI claims file the delivery of the 5010 transactions executed in multiple integrated releases throughout 2011

Roles and Responsibility:

  • Worked with the EDI crosswalk team to identify incoming ANSI X12 fields where NPI information would come in and maps it to our internal Physician ID.
  • Identified the impacts areas in the EDI process and proposed workaround
  • Worked with Business rules engine BRE , a software system that executed IBC business rules in an EDI runtime production environment.
  • Worked on BRE error Management, EDI portal processing resulted in various BRE errors to the customers/vendors.
  • Identified top 10 BRE errors that resulted in 90 of all EDI errors.
  • Designed a Business process that isolated those top 10 errors and then defined and classified them for the customers and provided error resolution methods in a step-by-step procedures
  • Worked with HIPAA Transactions/mapping and Code Sets including ASC X12 837, 270/271, 276/277, and 835.
  • Played a leading role in the testing of various HIPPA transactions with Claredi and in getting it certified
  • As a Sr. EDI Specialist, served as the primary implementations interface for national and regional accounts
  • Served as a technical resource for all Data Feeds as well as technical resource for Network and ANSI X12 transaction troubleshooting
  • Focused experience in the area of systems integration, business workflow solution design, planning and implementation consisting of a variety of technology platforms, systems, and encompassing business problems of all types.
  • Performed testing and quality control checks on mapping projects.
  • Consulted with customers to obtain EDI requirements, mapping specifications, and project objectives.
  • Developed and maintained applicable documentation for the entire EDI Process and Keeping abreast of all technical and procedural changes, various additions and enhancements to the data exchange products and associated communications infrastructure affecting EDI.
  • Received and sent transactions/data to the Application and verified the output with Input using the Data Requirements, Data map and EDI Standards.
  • Hands on experience on HP Quality Center 10.0, including Defects Management, Requirements, Test Plan and Dashboard.
  • Worked on Defect management, including Opening New Defect, Defect Assignment, Setting up priority, Current status, Description, setting up different environments DEV, SYT, SIT, PROD and PVS and many more activity related to Defects.

Environment: HP Quality Center 10.0, Caliber RM, SAP, MS Office, Windows 2000, Windows Vista, MS Visio, HP SharePoint, MS Project, MS Visio, SQL, SOA Infra, BPML, XML, SOAPUI and WSDL.


System Analyst

Confidential nation's leading provider of healthcare services, a company comprised of locally managed facilities that includes about 164 hospitals and 106 freestanding surgery centers in 20 states and Great Britain and employing approximately 183,000 people. Nearly five percent of all inpatient care delivered in the country today is provided by HCA facilities.As a Business Analyst, I was involved with drafting the migration plan for the Claims Processing data which needed to be migrated from the Mainframe to the SQL Server environment along with HIPAA 5010 compliance for the new MMIS Medicaid Management Information System system.

Roles and Responsibilities:

  • Gathered requirements from stakeholders for provider management and member management.
  • Identified and validated business rules and data elements.
  • Developed the stakeholder list and created stakeholder assessment matrix to prioritize them.
  • Developed and Maintained Requirements work plan and assessed the performance metrics of the team members.
  • Created and Analyzed Business Requirement BR and Functional Requirement, Directed development team to developed Member login Web Portal Intranet .
  • Worked on Document Management, used Workflows to route documents from person to person so they can complete their document management tasks, such as Reviewing documents, approving their publication and managing their disposition.
  • Modeled the 'as-is' process flow and the 'to-be' process flow and analyzed the gap and developed the action steps to fill the gaps.
  • Proposed strategies to implement HIPAA 5010 in the new MMIS system and worked on planning and documentation.
  • Worked extensively with ETL process, migrated data from old system to new one, make sure that data format match new system requirement.
  • Facilitated JAD sessions for Requirement Validation with Client Dept. of Health Human Services DHHS .
  • Worked on Electronic Data Interchange EDI , and Implementation knowledge of HIPAA code sets, ICD-9, ICD-10 Migration, Mapping, Verification of ICD .
  • Developed UAT test cases associated with the functional requirements.
  • Analyzed Health plan claim processing ANSI X12 837/835 file and Premium Payment ANSI X12 820 file specifications under HIPAA framework.
  • Prepared implementation plan and negotiated agreement on EDI file specifications with Trading Partners and vendors in accordance with HIPAA guidelines.
  • Interfaced with technical staff, trading partners, Clearinghouses and internal staff including programmers on all HIPAA related information and changes.
  • Teamed up with Senior Management, Legal to formulate EDI Trading Partner Agreements in accordance with HIPAA compliancy rules.
  • Wrote companion guides for several EDI formats evaluating system requirements and business rules.
  • Analyzed different Data cross-walks, complicated logic look ups required by different fields for the source to target transformations.
  • Broke down the services from the HCA MMIS Logical Design into multiple layers of normalized functionality that correspond to utility services, general business services and Medicaid specific services.
  • Participated in developing Team Foundation Server TFS test plan, test scripts, and test scenarios and designed user documentation.
  • Worked with legacy team in developing BRD for multiple system change requests and participated in System Testing.

Environment: MS Office, Windows 2000, .NET, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Oracle, SOA, HTML, FMS/3


Business Analyst

A leader in healthcare for more than 75 years, Baxter assists healthcare professionals and their patients with treatment of complex medical conditions. It also deals with global medical products, services, expertise in medical devices, pharmaceuticals and biotechnology. I worked with an application that was taking care of Online Account Services that included Billing Application, Checking the bill history, Changing customer profile, Ordering auto insurance ID cards and Modifying the load provider details.

Roles and Responsibilities:

  • Interacted with stakeholders and gathered requirements as per the business needs.
  • Implemented RUP methodology for iterative and incremental development of the system.
  • Involved in the planning of the RUP iterations and documenting of the artifacts throughout the various phases of the development process.
  • Conducted GAP analysis by understanding the AS-IS system and the TO-BE system requirements by having discussions with the SME's.
  • Created test cases and test scenarios based on HL7 interoperability specifications like workflow, performance, Load and networking.
  • Worked on Facets including Claim processing online and batch adjudication , Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
  • Maintained Quality Center 10.0 and CaliberRM for quality management issues during defects monitoring meetings.
  • Compiled the Vision Document and composed detailed Use Case Specification Documents in Rational Requisite Pro.
  • Used UML to perform Use-Case analysis to capture the dynamic aspect of the application.
  • Developed State Diagrams, Activity diagrams and Class Diagrams in MS Visio using UML for various modules of the project.
  • Created Process Flow Charts, Business Requirements Documents, Functional Specification Documents.
  • Worked on Required Traceability Matrix RTM in Rational Requisite Pro for traceability of requirements through test cases.
  • Involved in managing the Daily Standup meetings and also ensured that quality standards were enforced as per the build-release schedule.
  • Developed Test Plan and Test cases based on the Use cases and Functional specifications and also performed User Acceptance Testing UAT of the functionality of the application by inserting varying data on different test runs.
  • Developed Flowchart and process diagram using Microsoft Visio.
  • Worked on Privacy Impact Assessment PIA and HIPPA including Consent and Limiting use after Security Breach.
  • Contributed in reviewing and editing of the test scripts.

Environment: Windows, MS Office MS Word, MS Excel, MS PowerPoint, MS Visio , MS Access, MS Project, Rational Rose, Community Manager, BPML, SQL, Clear Case, Agile, Informatica 7/8, Load runner


Business Analyst

Confidential is the nation oldest proprietary national organization providing health care personnel at all skill levels in all settings. There are more than 300 independently owned franchise locations nationwide. I worked on System Requirement Analysis and CRM chain of the company it also dealt with Data handling of company at server level computation.

Roles and Responsibilities:

  • Identified System Integration Requirements, and coordinated the collection and verification of business needs.
  • Collected and documented business processes as well as business rules.
  • Participated in the identification, understanding, and documentation of business requirements, including the applications capable of supporting those requirements.
  • Translated the business needs into system requirements, communicating with the business on a non-technical level, and with the System Analyst on a more technical level.
  • Have been using these HL7 standards for integral for system integrations, inter-operability and compliance. I used them to support clinical practice and the management, delivery, and evaluation of health services.
  • Documented and delivered Functional Specification Document so that development team can be directed to develop Member Web Portal.
  • Created and analyzed Business Requirement BR and Functional Requirement to the project Team.
  • Responsible for multiple roles such as requirements gathering and solution development across the full insurance life cycle from CRM marketing, sales, service to underwriting quoting, policy administration, commissions broker management, claims, financial reporting and analytics for Property and Casualty division.
  • Worked FMS/3, Analyzing result and based on that created report to help making decisions.
  • Designed and developed the database for various projects.
  • Helped the business units understand how Data warehousing and Data mining techniques can help them do their decision making in a more organized and easy manner.
  • Collaborated with development architect and the business to develop both high-level and detailed application architecture to meet the business needs.
  • Conducted User Acceptance Testing UAT with the help of Test Director.
  • Assist the PM in setting realistic project expectations and in evaluating the impact of changes on the organization and plans accordingly.
  • Developed Test scenarios and implemented Test plan, providing key input in working with users in defining project and system requirements.
  • Conducted Project related Presentations.

Environment: Windows, MS Office, MS Visio, Lombardi, Oracle, SQL, Test Director, UML, MS Project, Rational Requisite Pro, Rational Clear Quest, FMS/3.

Hire Now