SUMMARY

• 8+ years of Business Analyst experience in HealthCare industry such as EMR/HER, Claims, HIPAA and EDI Acts.
• Experience in designing and evaluating of various documents including the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM), Product Requirement Specification (PRS) and testing documents.
• Experienced in all phases of the Software Development Life Cycle (SDLC) Waterfall methodology, Agile methodology (Scrum), Rational unified process (RUP), Rapid Application Development (RAD).
• Experienced in performing GAP analysis by identifying existing technologies, documenting the enhancements to meet the end - state requirements.
• Excellent Analytical, methodical, and resourceful approach to problem solving, identifying and documenting root causes and corrective actions to meet short and long term business and system requirements.
• Hands on experience in Conducting Joint Application Development JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Extensive working knowledge of health care and clinical sector claims management, Splits Claim, HIPAA regulations and 270,271,275.276,278, 835,837P, 837I, 837D EDI transactions.
• Expertise in HMO, PPO, POS, EMR Business processes, Medicaid and Medicare Processing and Scrubbing of Medical Claims.
• Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
• Experience in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology. Extensively Knowledge in the Member Enrollment and Medical Billing information.
• Experienced in the documentation of high-level Standard operating procedures (SOP), CMS documentation related to MMIS Certification and comprehensive criteria using multiple elicitation methods such as conducting brainstorming sessions, review of records, interviews, evaluation and seminars on requirements.
• Strong understanding ofFACETSandFacets Data Modelworking on data model and data extracts.
• Expertise in UML as a business analysis methodology for application functionality designs using IBM’s Rational Rose and MS Visio. Hand on experience on Tableau, e-Prescribing - NCPDP SCRIPT Standard, Word, Excel, FHIR IGs, PowerPoint, and MS Project.
• Good knowledge of various database languages (SQL, MySQL, XML) Jira, SharePoint, Visio and operating hardware and software applications including TOAD, Crystal Reports, Oracle Discoverer, Query Analyzer and SQL Navigator.
• Expertise in writing SOP, Manuals, Proposals, User Guides, RFPs and CMS Documentation.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment.
• Extensively participated in verification of EDI file formats against Standards. Used Validator Self-Testing Tool to accept claims from the Trading Partner, further monitored errors.
• Liaised with QA team to design & implement of Test Plan, Test Scripts and Test Cases for Functional, System, Integration, UAT, and Regression Testing RT based on the Design Document and User Requirement Document for the Functional, Security, and Performance Testing.
• Creation and execution of test plans, test cases and Black-box testing, device testing, integration testing, regression testing, User Approval Testing (UAT), Training Material, NCPDP SCRIPT Standard, load/stress testing and output testing for the QA team, and defects tracking/reporting (JIRA, Bugzilla).

PROFESSIONAL EXPERIENCE

Confidential, Summit, NJ

Business Analyst

Responsibilities:

• Gathered requirements for setting quality metrics and standards for enhancing managed health care and performance while processing newborn baby data.
• Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
• Conducted JAD sessions, Medicaid meetings, workshops to gather requirements from various stakeholders and SMEs.
• Expertise in implementation of Standard operating procedures (SOP), CMS documentation related to MMIS Certification
• 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
• Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.
• Gathering requirements for a data collection and reporting system and researching various topics, scheduling meetings and documenting meeting minutes.
• Performed a High-level analysis of the requirements from a business perspective to determine the feasibility of constructing the new application.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims and HIPAA Act Rulesand Regulations HIPAA transactions
• Worked on FHIR, C-CDA, HL7 and 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
• Initiated with a comparison report of 270 Eligibility, Coverage or Benefit Inquiry (VX092A1) vs.270 Eligibility, Coverage or Benefit Inquiry(VX279).
• Perform research onMember, Provider, Clinical Data, Claims, Authorization, Appeals and Grievancesdata from Facets back end and front end application system for reporting purposes.
• Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, that include Functional and Non-Functional specification to hand off to development teams.
• 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.
• Extensive use ofFacets back end tablesand front end application system for data validation purposes.
• Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
• Acted as User Acceptance Testing coordinator and monitored business testing and interfaced with the development team regarding defect status and fixes on daily basis.
• Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.

Confidential, Chicago, IL

Sr. Business Analyst

Responsibilities:

• Conducted walkthroughs with the end users and stakeholders to gather the modification requests from the user to upgrade or change the specifications for the product.
• Conducted JAD sessions, Medicaid meetings, workshops to gather requirements from various stakeholders and SMEs.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the Analyzed the Business Requirements Document (BRD), modified the Master Test Plan and prepared detailed Test Cases for the UAT.
• Created Swim Lane Diagrams andbusinesslogic & calculation spreadsheets for variousbusiness processes.
• Performing business process support reviewing user questions, making data updates, providing one-on-one user training, identifying process improvements.
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Worked with SME's and business users to gain in-depth understanding of the business' mission, objectives, purpose and processes.
• Extensively worked with HIPPA X12 EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim-status), 834(Benefit-enrollment), 835(Payment/remittance advice), 837(Health care claim).
• Performed data mapping to define the Source data on 834 Benefit Enrollment and Employer Group File (EGF) EDI Transfers.
• Worked closely on 837 I/P transaction code for Health care claims and was involved in Validation of HIPAA for 270/271 (health care benefits and eligibility), 276/277 (Claims Status), 835 (Payment/Remittance advice), 834 (Benefits Enrollment) EDI transactions.
• Assisted in development of test cases based on functional requirements for claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Created Process Models for (a) Initial Enrollment, First Billing and Payment and (b) Post Enrollment - Subsequent Recurring Billing and Payment.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets. Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
• Wrote transformations for data conversions into required form based on the client requirement using Teradata ETL processes.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Manage and analyze data communication channel to ensure compliance security requirements in accordance to ISO, HIPAA and PCI guidelines. Coordinated with Project Managers to resolve risk issues and ensure compliance of Security System related to the HIPAA.
• Worked with PPI Teradata tables and was involved in Teradata specific SQL fine-tuning to increase performance of the overall ETL process
• Involved in requirement gathering phase (Provider, Claim components and HIPAA). Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• Manage and lead day-to-day operations of system upgrade to comply with new federal reporting requirements and security protocols including HIPAA.
• Generated and maintained SQL Scripts to perform back-end testing on the oracle database.
• Worked closely with the development team in user interface UI screen mockups and UX wireframes
• Identified bugs during the test phase and reported them using HP Quality Center and Maintained Traceability Matrix throughout the project.
• Developed Test Plans and Test Execution Procedure Document based on the Business & Functional Requirement Document and numerous Test Cases and Test Scenarios to cover overall aspect of quality assurance.
• Assisted End User in performing User Acceptance testing and performed testing of the end result files created by the development team to verifying whether all the User Requirements were catered to by the development effort.

Confidential, Jacksonville, FL.

Business Analyst

Responsibilities:

• Gathered business requirements through surveys, prototyping and observing from account managers, finance manager, and independent advisors and got an accurate understanding of their needs.
• Facilitated interview, one on one and brainstorming sessions with SME's User's in understanding the requirements pertaining to billing Origination to billing Processing.
• Assisted and written System Requirements Documents SRD, including Functional and Non-Functional requirements and Software Requirement Specifications SRS as per SEI-CMM standards.
• Conducted the JAD Sessions with stakeholders and developers to have a clear picture of a project.
• Developed Use cases and activity diagrams and analyzed business requirements.
• Created UML-based feasibility studies and Use Case Models to communicate those ideas to the developers. Followed the UML based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, and Sequence Diagrams.
• Manage company's EDI catalog for prospective EDI customers.
• Worked on improvement of Claims Reimbursement User Interface for a better experience and in corporate changes as per FHIR, Clinical Data, C-CDA, HL7 and HIPAA guidelines using the gap analysis.
• Conduct project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.
• Worked with HIPAA Team for RIMS Companion Guide of X12 ANSI 270/271 and 276/277 Companion guides for Professional and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving 837 HIPAA compliance and 835 Remittance Advice.
• Wrote SQL scripts for creating performance evaluation reports.
• 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.
• Created use-case scenarios and storyboards in MS Word and MS PowerPoint for better visualization of the application.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models and developing of SOP, Manuals, Proposals, User Guides, RFPs and CMS Documentation.
• Responsible for support and enhancement requests for a SQL data warehouse and transactional database.
• Documented the evaluation of various reporting tools like Oracle Analytics/Business Objects, SOP, Manuals, Proposals, User Guides, RFPs, CMS Documentation and made recommendations about the product depending on the reporting requirements.
• Developed Test Cases and Test Plans on the basis of requirements and also did manual testing of the functionality of the application to ensure that the application is able to handle a lot of data.
• Collaborated with the QA testing team to develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Involved in the User Acceptance testing UAT to check the reliability for end users.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.

Confidential, ORANGE, CA

Business Analyst

Responsibilities:

• Prepared theBusiness Requirement Document BRDandfunctional requirement document FRD and non-functional requirementsfor the enhancement of the existing services.
• Conducted the JAD Sessions to 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.
• Worked with SME's and business users to gain in-depth understanding of the business' mission, objectives, purpose and processes.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements withinFACETS.
• Involved inFacetsOutput generation, Interface development and Facets Migration Projects.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure, features and functionality with the new business design using the "As Is" and "To Be" methodology.
• Implement 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 on improvement of Claims Reimbursement User Interface for a better experience and in corporate changes as per FHIR, Clinical Data, C-CDA, HL7 and HIPAA guidelines using the gap analysis.
• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance. Responsibilities include the Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system and HL7.
• Developed Requirement Traceability Matrix (RTM) for all the changes made during the project development and generated report.
• Validated the following Edi 837 (Health Care Claims or Encounters), 835 (Health Care Claims Payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrolment/Dis-enrolment to a health plan).
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models.
• Created use-case scenarios and storyboards in MS Word, SharePoint, Visio, Tableau and MS PowerPoint for better visualization of the application.
• Responsible for support and enhancement requests for a SQL data warehouse and transactional database.
• Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables.
• Troubleshoot EDI, and XML document errors and troubleshoot translation and mapping errors.
• Designed Test Plans, Scripts after analyzing various scenarios/requirements & performed defect tracking using Test Director & Clear Quest and Prepared test data from user stories, write and execute test cases in JIRA.

Confidential, Nashville, TN

Business Analyst

Responsibilities:

• Gathered Business Requirements upon clearly analyzing the scope of the project and analyzed the User Requirements from walkthroughs and interviews with the business groups and in-house stakeholders, and many other departments like accounting, fund management, human resource and thus converted User Requirements into Business Requirement Documents (BRD).
• Documented the AS-IS and TO-BE Business Process Management (BPMN) and presented in the form of Use Case scenarios by doing GAP analysis.
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Involved in various Facets Data models like Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice Benefits, Product and Plan.
• Coordinate with Health Insurance Exchange (HIX) program staff and other stakeholders to define and develop requirements for correspondence generation across various business lines.
• Identified and analyzed trends in EDI failures, collaborating with new EDI partners to develop innovative solutions.
• Got involved in designing future state processes for HIPAA transaction processing EDI's 837,835, 270 and 271.
• Facilitated Scrum meeting with technical/non-technical team, Accounts updating, data analysis and sharing with XML patterns, SME's to clarify business rules & solve impediments, rectifying the regulatory issues with SME's and translated Functional requirements into User stories using JIRA.
• Liaison and Coordinated in resolving HIPAA/EDI mapping issues arising from the third party systems.
• Articulated UML through Use Cases, use case document by specifying actors, normal flow, sub flow, alternative flows for each and every use case.
• Designed a new matrix covering all the conceptual parameters of the new system.
• Completed validation, testing, and Implementation with the defined scheduled timelines.
• Conducted User Acceptance Testing (UAT) and wrote SQL scripts for back-end testing.