SUMMARY

• Experience and versatile Business Analyst with 6 years of extensive experience in Business Analysis in Health care domain.
• Sound knowledge of Medicaid, Medicare Healthcare policies, benefits, plans and medical products and well - versed in EDI - HIPAA transaction code implementation - 834, 820, 837, 835, 270, 271, 276, 277, 278, 999 and experience working with member eligibility and enrollment modules and claims processing applications
• Vast Experience in Project Management Skills, Business Analysis, Business Modeling, and Data Modeling. Extensive experience in conducting Gap Analysis, Business Process Re-engineering.
• Experience with Health care and Care management projects as well as Health and Human Services programs, Medical Claims from the Provider/Payer side regulatory environment including HIPAA
• Configured and Implemented Altruista Care Management Application system to design the health Plan, Data Integration, Workflow management.
• Responsible for design, build, testing and implementation for Epic Home Health and Hospice Billing and Clinical applications.
• Testing of Epic billing reports (hospital billing and insurance billing) for Epic billing output and interface accuracy.
• Proficient experience in the FHIR (Fast healthcare Interoperability Resource) worked closely with EHR and API
• Strong understanding and hands on experience working with HL7 (traditional version) and (xml-based version) and FHIR.
• Widespread knowledge of EHR/EMRs Electronic Medical Records, HL7 and its Patient Protection and Affordable Care Act PPACA.
• Experienced with Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Extensive knowledge of Software Development Life Cycle (SDLC), Capability Maturity Model (CMM) and exposure to various SDLC methodologies like Agile, Waterfall and Scrum.
• Proficient in authoring Business Requirement Documents (BRD) into System Requirement Specifications (SRS) and identifying interface and business process specifications.
• Used SharePoint for Customization, Integration, Creating Work flows and Saving Project related documents.
• Experience with Microsoft Access, Visio, Project and Excel or similar tools
• Strong data management skills including understanding of requirements determination, data organizational structures, organized testing approaches report design and development.
• Strong understanding of health care analytics and ability to effectively interface with employees at all levels.

TECHNICAL SKILLS

Web Technologies: ASP.Net, VB.Net, XML, HTML.

Operating System: Windows, UNIX, DOS.

Databases: Oracle, Teradata, SQL Server, RDBMS, MS Access, Mainframe

Languages: Java, Visual Basic, DB2, SQL Server, C, C++, SQL.

Design Methodologies: OO Design, OOPS, Agile, Rational Unified Process (RUP), UML, JAD, TQM.

Design Tools: Rational Rose, Rational RequisitePro, Rational ClearCase, Rational ClearQuest.

Project Management Tools: Ms Visio, Ms Excel, Ms PowerPoint, Ms Office, Ms Project, Ms Word, TOAD, Crystal Report, Ms SharePoint.

PROFESSIONAL EXPERIENCE

Confidential, Eden Pairie MN

Business Analyst

Responsibilities:

• Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time transactions like 270/271/276/277 for Medicare and Medicaid programs inFACETS.
• Developed test cases based on the crosswalks and compliance guidelines for 277/288, 834, 835, 837 Professional, Institutional and Dental claims and for 270/271 eligibility benefit inquiry and response
• Created Use Case Model using Rational Rose for developers and other stakeholders to understand the business process, depict roles, and procedures
• Create and execute revenue cycle medication Epic billing data and reports from decision support and billing systems. Analysed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed
• 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.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Responsible for providing database solutions using MS Access/ SQL Server/ Oracle database and Created reports using Crystal Reports and Oracle Forms/Report.
• Extract, manipulate and analyze data and create reports using T-SQL. Used TSQL to develop Indexes, Primary Keys, Constraints, etc., to further develop tables
• Experience in extensive database testing and Back End Testing using SQL queries with MySQL database Performed Manual Testing of the Application to determine ease of usability.
• Decreased customer complaints and dramatically reduced post-implementation support. Involved in forming strategy for increasing call conversions.
• Exposed to using ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both Inpatients and out patients.
• Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system. Analysis and Design of the FACETS data model to ensure optimal system performance and tuning.
• Worked directly with Medicaid Executive Staff to manage the Medicaid program related business and IT capabilities within Healthcare Reform from concept through to operational readiness.
• Assisted JAD sessions to identify the business flows and determine whether the EDI X 12 Transaction, Code set and Identifier aspects of HIPAA affect any current or proposed systems.
• Provided business and mapping expertise during a transition of the EDI applications from the GXS Application Integrator (AI) to GIS.
• Facilitate all agile ceremonies including daily stand-ups, weekly grooming, retrospective, and review and planning session.
• Participated in frequent agile team meetings (Scrum planning, daily stand-ups, retrospectives) to provide guidance to an agile product development process.
• Master Data Management MDM contract with the Centers for Medicare and Medicaid Services CMS to provide enterprise data services, identity resolution for Medicare and Medicaid beneficiaries and providers to support the agency's information systems.
• Worked on customizing the claim module ofFACETSfor reprising Nursing home claims. Data mapping on Enrollment Module (EDI 834) ofFACETS. Experience in integrating claims, eligibility, provider and data information using facets.
• Used JIRA tool to track and maintain different versions of the project documentation.
• Coordinated daily activities with the IT Developers, QA and Product teams along with the project management group.
• Generated test data using X12 generator for transactions 277/288, 834, 835, 837P/I/D. Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 5010 standards.

Confidential, St Louis MO

Business Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Experienced in using JIRA to create and assign User Stories and maintain test cases, requirement backlog.
• Interacted with various HMO, PPO, Medicaid/Medicare Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues.
• Proactively involved in imparting Agile and Scrum values to the team and helping the team to continuously improve the agile process.
• Converted CSV flat files into HL7 messages & modified and translated segments of HL7 messages to properly send to EPIC.
• Participated in testing of Orion Rhapsody Route to receive and process HL7 messages to Websurv
• Customized and enhanced the Test Scripts defining various Checkpoints, Synchronization points, Input value,
• Expertise in development of High-level design, Conceptual design, Logical and Physical design for Database, Data warehousing and many Distributed IT systems.
• Extensively involved in the modeling and development of Reporting Data Warehousing System.
• Developing and implementing an Agile process for software delivery, while coaching, training and guiding the project managers
• Developed Test Cases and prepared test scripts using SQL to test transformation logic in the data and Executed UNIX shell scripts for data loading, job scheduling and SQL script execution.
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Working knowledge of Epic Rx /Epic Lab/Epic Care Inpatient/Health Information Management and Chart Tracking.
• Extensive healthcare experience in Medical Imaging, EHR/EMR, Mobile Apps, Medicare-Medicaid, HIPPA, HIX on EPIC software applications
• Capturing data and building reports for clients in SSRS and creating stored procedures using T-SQL daily.
• Widespread knowledge of EHR/EMRs Electronic Medical Records, HL7 and its Patient Protection and Affordable Care Act PPACA
• Using FACETS for various health insurance areas such as enrollment, member, Products and other FACETS related modules
• Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA
• Managing improvements: scope definition, Agile change control, governance & reporting, integrate consultants, embedded Quality Assurance (QA), manage risks, engage stakeholders and project value realization
• Communicated with the Developers to make them understands the requirements and feature need for the end user tested the Functionality of the application through manual Testing.
• Scripting in T-SQL from tables in the student database, developing test procedure cases.
• Writing T-SQL code for stored procedures, managing tasks and meeting deadlines in response to ad-hoc requests.
• Worked extensively in Query Optimization and Performance Tuning using tools SQL Profiler, Index Tuning Wizard and database Engine Tuning Advisor.
• Conducted brainstorming sessions with the business users and SMEs to elicit requirements and worked in the creation of Agile Epics, user stories, Acceptance criteria documents.
• Experience with Medicare, Medicaid and commercial insurances in HIPAA, ANSI, X12 formats including 270/271, 276,277, 278, 835, 837, 997.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.

Confidential, Scranton PA

Business Analyst

Responsibilities:

• Analyzed, collaborate, and worked closely with the stakeholders and the SME to gather the requirement and to prepare the appropriate BRD for the development team.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Expert in TSQL, creating and using Stored Procedures, Views, User Defined Functions, implementing Business Intelligence solutions using SQL Server.
• Capture Feature/Function information at varying levels of granularity and document them in a requirements management tool (e.g. Microsoft TFS, JIRA, etc.)
• Designed the HL7 standards so the EHR/EMR data could be retrieve from the provider easily for the operations
• Working knowledge of implementing software development projects using methodologies such as Waterfall, Rational Unified Process, and Agile/Scrum.
• Experience with EPIC user and provider record provisioning, including the development of role-based access, security classes, and user profiles
• Creating SQL Stored Procedures and User-Defined Functions using T-SQL for data fragments in Documents for Stakeholders.
• Used SQL, Data Warehousing and Data Cleansing for the arrangement of customer data.
• Expertise in development of High level design, Conceptual design, Logical and Physical design for Database, Data warehousing and many Distributed IT systems
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Created ETL documentation such as EDI X12 837(P,I), 834 and 835 Data Mapping, Transformation logic for Main Frame Layout, Updating Meta data documents for new Platform.
• Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrollment).
• Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins.
• Build Platform features, user stories, and maintain backlog with priorities, using Rally and JIRA platforms; Drive HLD, Low Level, and Integration (SOAP, REST, JSON, XML etc.)
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS. Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS