SUMMARY

• Experienced and distinguished Healthcare Business Analyst and Business Systems Analyst with around 9+ years of experience in Software Development Life Cycle (SDLC) and Business Process Re - engineering.
• Experience working in various SDLC methodologies such as Waterfall, AGILE (SCRUM), RUP (Rational Unified Process), RAD (Rapid Action Development).
• Proficient on creating artifacts such as Business Requirement Document (BRD), Functional Specification Document (FRD), Requirement Traceability Matrix (RTM), System Reference Document (SRD), System Manual and Operations Guide (SMOG).
• Strong experience in Data Analysis, Data Modeling, Data Mapping, Data Profiling, Data Migration, Data Conversion, Data Quality, Data Governance, Data Integration and Metadata Management Services and Configuration Management.
• Extensive experience and good understanding in medical claims management process, claims adjudication process, Medicaid and Medicare service, insurance sector, provider relation, enrollment, and benefit administration. Experienced with Medicare advantage implementations.
• Generated and reviewed various documents including project scope, project objectives, business rules, test plan, change request, RTM (Requirement Traceability Matrix), Use Case, Test Case, Defect Report, SOW (Statement of Work), WBS (Work Breakdown Structure).
• Experience writing SQL queries and prepared custom reports and data analysis.
• Proficient in Requirement management tools such as JIRA, HPALM, RALLY and experience in creating UI Mock-up screens, Wireframes and prototypes by using AXURE RP and Balsamic tools.
• Experienced in lead and conducting JAD sessions meeting reviews and walkthroughs.
• Created UAT test cases in HP ALM/Quality Center tool and worked with the business users to validate the functionality in UAT.
• Experienced in using SQL queries for data extraction and back-end testing.
• Experienced in creating Test Cases, Test Plan, and Test Data. Performed User Acceptance Testing (UAT) working with team members.
• Experience in conducting GAP analysis, User Acceptance Testing (UAT), SWOT analysis, Cost benefit analysis and ROI analysis.
• Skilled in leading teams of diverse backgrounds to make sound business decisions based on analyses of short- and long-term business needs.
• Extensive Claim experience for Provider, Payer, Clearinghouses, Pharmacy Expert level knowledge of healthcare industry applications and processing, EDI transaction sets and formats.
• Implementation of metadata management system for an end-to-end process and governance framework for creating, controlling the metadata schema.
• Skilled in project management, SDLC tools and methodologies, requirements definition, documentation of functional and technical specifications.
• Expertise in source data profiling, data quality analysis, reference data identification, data governance, source to target mapping, master data match/merge rule for golden record and trust rule set up.
• Proven ability to develop positive relationships though team-building and mentoring junior staff.
• Strong Experience in Smoke, Functional, Regression, Performance and User Acceptance testing for the highly structural and complex systems. Extensive experience in Black Box Testing, Functionality Testing, System Testing, Regression Testing, UI Testing, User Acceptance Testing (UAT), Bug tracking system & process and Database Testing using SQL.
• Expertise in Population Health Management and Risk Adjustment experience.

TECHNICAL SKILLS

Business Skills: Business Process Analysis & Design, Requirement Gathering, Use Case Modeling, JAD/JRP Sessions, Gap Analysis and Impact Analysis.

Methodology: RUP, Agile, and Waterfall.

Management Tools: Rational Rose, Requisite Pro, Clear Quest, Clear Case, Serena Team Track and MS Visio, MS Project, JIRA, Azure DevOps

Business Modeling Tools: MS VISIO, AXURE RP, Balsamic

Testing Tools: ALM/Quality Center, Quick Test Professional, Rational Team Test

Database: Oracle, DB2, MS SQL Server.

Reporting Tool: Business Objects, Crystal Reports, SSRS

Operating Systems: UNIX, Windows

Office Tools: MS Office (Word, Excel, Power Point, Outlook), MS Visio, MS Project

PROFESSIONAL EXPERIENCE

Confidential, Minneapolis, MN

Sr. Business System Analyst/IT Business Analyst/Healthcare Business Analyst

Responsibilities:

• Gathered detailed business requirements from end user community into use-cases and produced accompanying workflow diagrams
• Participated in discussions with technical team to clarify existing business processes and identify opportunities for improvements. Translated business processes to flow diagrams.
• Worked in Software development life cycle (SDLC) using Agile Scrum methodology.
• Worked on different EDI transactions like 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270/271 for Eligibility inquiry, and 276/277 for claims status.
• Control on designing Enterprise data dictionary, Reference data and data catalog design.
• Defined Business rules in Informatica Data Quality (IDQ) to evaluate data quality by creating cleanse processes to monitor compliance with standards and assist in resolving data quality issues.
• Involved in Data modeling using Informatica IDQ and MS Visio.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Manage business glossary, metadata, standard and system reference data and their relationships.
• Define/Design metadata management framework which can be leverage at enterprise level to manage enterprise metadata of all the sources systems.
• Created transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 835, 837-(I, P, & D), 835, 834, 820.
• Worked with Data governance team to maintain data models, Metadata and Data Dictionaries.
• Perform Benefits Configuration for new and existing products.
• Tested Schemas of EDI ANSI X12 Claims (837-HealthCare Claim and 267-Individual life, Annuity and Disability Application) and Eligibility forms in XML.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Wrote complex SQL queries like Joins, Update, Stored Procedures, Indexes, Reports, ETL packages to understand the low-level requirements.
• Effectively test various applications to ensure that claim adjudication applies benefits according to the benefit plan and correspondence to provider and members meets all guidelines.
• Involved in various Facets Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice, Benefits, Product and Plan.
• Utilized Informatica Data Quality (IDQ) to determine the data quality issues for the MDM data.
• Analyzed User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Done transaction and position records, reference data and attributes through the use of SQL Query.
• Conducted Unit Acceptance Testing (UAT), System Integration Testing (SIT), and regression testing of unemployment Insurance registration domain. Experience of working through complete SDLC process of registration domain of unemployment insurance.
• Define and design the Data Acquisition, Transformation, and Data Cleansing approach for the MDM implementation.
• Benefit coordination and configuration, updated, adjusted, and revised fee schedules, coding, rates, provider contracts, database, claims and information via FACETS.
• Review, validate, and record metadata and data quality information.
• Supported development of UAT cycle test scripts, Review User Acceptance Test Plan (UATP) and attend walkthrough.
• In-depth exposure to System Developement Life Cycle (SDLC) on each project phase.

Confidential, Minneapolis, MN

Sr. Business System Analyst/Healthcare Business Analyst

Responsibilities:

• Facilitated Sprint Planning meetings, Daily scrum, sprint review, product backlog refinement meetings and sprint retrospective meetings.
• Helped the team to write and split User stories, breakdown Epics.
• Used JIRA to maintain product backlog and sprint backlog and to create and track user stories, Sprint planning, tracking and managing sprints, created status reports and burn down charts.
• Confluence was used to maintain project documents such as project plans, project scope, and status reports and to assign tasks.
• Documenting metadata lineage through integrations using the metadata exchange capabilities of the tools.
• Used IDQ to profile the project source data, define or confirm the definition of the metadata, cleanse and accuracy check the project data, check for duplicate or redundant records, and provide information on how to proceed with ETL processes.
• Designed IDQ mappings which are used as Mapplets in Power center.
• Defined epic, features, product backlog and tasks on JIRA following Agile principles.
• Facilitated and participated in Agile rituals including,productbacklog release, backlog stand-ups, and sprint planning, release planning, Iteration sprint review and retrospectives.
• Architected Reference master data hub that serves as a “single source of truth” for Reference data.
• Lead JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Used JIRA to create and maintain User Stories and created UAT test scripts.
• Responsible for configuring, benefits, contracts, providers, UM models, claims Analyze.
• Configured system to calculate appropriate claim reimbursement for multiple business lines according to the benefit summary.
• Validating the data element against its standard reference data.
• Benefit coordination and configuration, updated, adjusted, and revised fee schedules, coding, rates, provider contracts, database, claims and information via FACETS.
• Maintained & updated Metadata repository (MDH) based on the CR's. Uploaded XML's in MDH for respective changes in Erwin model & updated MDH sheets regarding new codes.
• Worked on Medicaid Claims Resolution/Reimbursement for state health plans using MMIS.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Gathering requirements and preparing functional documents for Facets.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Worked on different modules ofFacetssuch as Claims, Members/subscriber, commissions, provider, billing.
• Involved on HIPAA translation-based claim processing systems (claims and encounters) and other ANSI X12 EDI implementations.
• Validated the HIPAA/ EDI transactions, tested the claims processing and Adjudication (EDI837 &EDI 835).
• Completed Data Analysis, Data Mapping for Medicaid projects and detailed report writing.
• Prepared documentation and reference materials for team members for future reference of FACETS configuration setup.Worked onProcess Flow Models and Captured Process flow diagrams.
• Involved in JAD sessions and cross team meetings.
• Facilitated the establishment and implementation of standards, guidelines and best practices that guide the various MDM and Data Warehouse projects within the organization.
• Created Use Cases and Use Case scenarios based on the requirements.
• Attended weekly status meeting and processed reports such as Adhoc and Error Reports.
• Constantly involved in review meetings and made sure testing is done based on the QA master plan and deadlines are met.
• Created business requirements and guidelines as it relates to receiving data, data quality, and data profiling.
• Queried variety of data warehouses and data structures using SQL.
• Setting-up Enterprise Data Catalog (EDC)tool on Linux platform Implement Data Governance in Informatica, EDC based on data validation performed in IDQ.
• Designed and supported in Test cases, Test plan creation and Companion Guide from development stage to production, including both internal and external requirements.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criterion for the requirements has been included in the UAT task plan.

Confidential

Business System Analyst/Healthcare System Analyst

Responsibilities:

• Responsible for the requirement-gathering phase and project plan.
• Responsible for requirements analysis, design and developing technical requirements.
• Documented Detail Business Requirements Successfully used Agile/Scrum Method for gathering requirements and facilitated user stories workshop.
• Documented User Stories and facilitated Story Point discussions to analyze the level of effort on project specifications
• Designed and supported an operational MDM implementation using Informatica MDM in accordance with DG enforced standardizations with a customized Informatica Party MDM data model.
• Prepared Business Requirement document to detail how Azure DevOps items maps to project Plan items for the technical system owners.
• Utilized JIRA Agile for managing requirements efforts while continuously completing RTM mapping against JIRA use case tickets.
• Generated Data Governance metadata and ensure Data Dictionary data is accurate.
• Facilitated scrum ceremonies (grooming, sprint planning, retrospectives, daily stand-ups, etc.).
• Worked with Product Owner, especially in refining and managing the product backlog.
• Testing 837 claims coming to us from providers.
• Performed Data analysis and Data profiling using complex SQL on various sources systems including Oracle and Teradata.
• Perform comprehensive data analysis of Source Data formatted in XML and XSDs
• Set up Data Profile and Scorecards using Informatica Developer Tool to monitor the quality of data, as a part of the Data Governance initiative.
• Tested (Validated and Verified) Medicate Management Information System (MMIS) and Integrated Eligibility System (IES) based on CMS requirements and State policies.
• Proposed FACETS claim adjudication procedures, standards, and editing guidelines.
• Healthcare claims and payment advice transactions, captured all related EDI data in the repository using FACETS, supported integrated EDI batch processing and real-time EDI usingFACETS. Accepted inbound transactions from multiple sources usingFACETS.
• Involved in claim adjudication process of facets application.
• Responsible for Medicaid Claims Resolution/Reimbursement for state healthcare plan using MMIS.
• Created Test Cases effort using systems such as HP-ALM and Rally.
• Piloted a move off Waterfall into Agile methodology, using JIRA Agile.
• Automate different workflows, which are initiated manually with Python scripts and Unix shell scripting.
• Designed, configured and deployed Amazon Web Services (AWS) for a multitude of applications.
• Assisted in developed of client centric Master Data Management (MDM) solution.
• Policy review to implement the blueprint requirements for Medicaid/MMIS, CHIP and Tax Credits benefits per CMS guidelines.
• Worked with facets edits and EDI HIPAA Claims (837/835/820) processing.
• Assisted Information Management team with Implementations and Processing of 837 Encounter and 834 Member Enrollment transactions (both inbound and outbound).
• Developed Business Crosswalks for EDI 837 I/P, 835, 834, 270/271 and 276/277 transactions per CMS - HIPAA implementation rules.
• Participated in all aspects of gathering and documenting requirements and analyzing those, transformed the requirements into functional specs and user stories, and after each sprint of development, then testing the NewMMIS incremental development. Primary responsibilities were to ensure that the system functions as designed, meets the requirements of the business community and conforms to all applicable Federal and state laws.
• Worked on the claims and provider modules of the NewMMISsystem.
• Provider inquiry about the status of claims. This involved checking the MMIS claims subsystem to see the status of claims sent and informing the providers if the claims have been suspended /denied or paid.
• Extracted and documented Business Rules for the MMIS system. Created “TO-BE” Use Case models. and descriptions and updated System Boundary Document during MMIS elaboration phase.
• Worked with theMMISapplication development team on dependencies with the ongoing project. Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category.
• Formulated system design, procedures, policies and workflows affecting Medicare/Medicaid claims processing in MMIS to compliance with government guidelines.
• Led and conducted JAD sessions for requirements gathering, analysis and design of the system.
• Designed Activity, Use Case, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate certain selection criteria and filter conditions.
• Generated reports using document generator of Quality Center.
• Supported development of UAT cycle test scripts, Review User Acceptance Test Plan (UATP) and attend walkthrough.
• Extensive backend testing using SQL queries, generating the reports to ensure the data integrity and validate the business rules.

Confidential, Hopkins, MN

Business System Analyst

Responsibilities:

• Conducted numerous JAD sessions with Business users, developer, CQA and SMEs.
• Evaluate business requirements and prepare detailed functional and technical specifications.
• Documented the Business Requirement Document to get a better understanding of client's business processes of both the projects using the Agile methodology.
• Prepared SSD (Solution Summary Document), HLD (High Level Design Document), SRI (System Requirements Inventory), RTM (Requirement Traceability Matrix) and also created BRC (Business Rule Configuration).
• Guide the development team to break down large and complex user stories into simplified versions of execution.
• Involved in creatingBusinessProcess Documentation. Identified Use Cases from the requirements.
• Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams using MS-Visio.
• Performed the GAP analysis to find the Root Cause of the issues.
• Created UI mockups using Balsamiq to review the requirements and provide feedback on the screen design.
• Worked with Claims adjudication, Membership Eligibility, Accumulators, Deductibles, Coordination of Benefits, and Overrides of the Claim Line detail.
• 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.
• Worked with HP ALM/Quality Center defect management system.
• Collaborated with quality assurance team to ensure testing efforts align with system deliveries and business processes
• Worked intensively on the PL/SQL for creating and working on the database for multiple projects.
• Analyzed User and Functional requirements to point out gaps between used SQL queries to extract the data from the database.
• Designed Process Models, Systems Diagram, Workflow, Activity Diagrams, Use Cases (UML) and Business Rules using MS Visio.
• Analyzed data and created reports using SQL queries.
• Coordinated with concerned developer/developer teams for design reviews per the business requirements for both UAT and Production testing.