SUMMARY:

• Over 7 year's expertise in Business and QA Analysis with hands on experience in Healthcare sectors.
• 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 .
• Complete Understanding of HIPAA Implementation guides and developing Business Specifications according to Mapping Notes for Transformation tools.
• Skills include defining Project Scope, Business Process Analysis, Business Process Re-engineering, Requirements Gathering, Data and Process Modeling
• Knowledge of the Back-End processes like Voucher Creation, EOB, Letter generation and 835 etc.
• Expertise in Business Process Modeling, Business Process Re-design and in designing Process Architecture.
• In-depth understanding of Enterprise Analysis, Business Process Management and Business Process Modeling.
• Knowledge in the ETL Extract, Transform and Load of data into a data ware house/date mart and Business Intelligence BI tools like Business Objects Modules Reporter, Supervisor, Designer, and Web Intelligence .
• Having very strong domain knowledge of US health Insurance plans like: HMO, PPO, POS, EPO, Indemnity plans, Medicare Medicaid.
• Extensive experience with data modeling and defining the conceptual and logical model of the data warehouse. Experience in Business Process Analysis, Business Modeling, Business Intelligence, Data Warehousing, Data Modeling, User Acceptance Testing UAT and Implementation.
• Extensive experience in Business Requirements gathering and writing skills with expertise in developing and documenting Business Requirement document BRD , Functional Requirement Document FRD ,Software Requirement Specification SRS across the deliverables of a project.
• Effectively used Rational Requisite Pro to organize, track and change requirements of the system.
• Expertise of UML in visualizing and documenting the artifacts using Use Cases, Use Case Diagrams, Activity diagrams, Class diagrams, Data Flow Diagrams, Business Flow Diagrams, Sequence Diagrams using MS Visio
• Extensive experience with Content Management tools such as Interwoven, Filenet, SharePoint and Documentum
• Experience in facilitating Joint Application Development JAD sessions, Rapid application development RAD sessions , conducting user interviews and acting as a liaison between the customers, development team and testing team
• Experience working with query languages like SQL
• Facilitated User Acceptance Testing UAT with the stakeholders and the business users as well as trained users to use the system configured.

Technical Qualifications/Skills List

• Tools:UML, Rational Rose, Requisite Pro, Clear Quest, Clear Case, Microsoft Visio, DOORS, MS Word, MS Excel and MS PowerPoint, Microsoft Office Sharepoint Server MOSS , Business Objects, Mercury Test Director, JIRA bug tracking tool, BugZilla, ERwin, MS Dreamweaver, MS Photoshop, uPerform, SnagIT
• Modeling Techniques:Use Case Modeling, UML Use case, Sequence diagram, Activity Diagram, Class Diagram, Entity Relationship Diagram , Object Oriented Analysis and Design
• Methodologies:RUP, RAD, Waterfall, Scrum and Agile
• Operating System:Win 95/98/NT/2000/XP, UNIX
• Database:SQL, MS Access, Oracle

Employment History:

Sr. Business Analyst

The HI-Exchange Project dealt with development of an online health information exchange HIE and a secure web portal to enable authorized Franklin Square Hospital providers to have fast and easy access to patient's electronic health record. The HI-Exchange web portal features EMR functions and Integrated Clinical decision Support tools for better care management. The project dealt with development of a Health Care Cost Containment System and implementation of an automated inter-operable web application that tracks patient medical history and health care plans via Viewer application and Electronic health records. The Viewer/EHR system provided online access to mobile patient records and improved communication in public health.

Responsibilities:

• Worked on modules related to Providers, Contract Claims and worked with Claims, Provider attributes, enabling EOB Remit rules associated with Provider configuration process in QNXT.
• Configured Claims, Provider and Member Data via EAI tools for RAPS file and TRR files to CMS for Risk Management.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Responsible for developing applications for physicians' electronic billing and scheduling, and electronic medical records EMR .
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Completed the documentation of Claims Scenario's for the source system
• Analyzed the requirements using Rational Suite Rational Rose, Requisite Pro and performed the iterative process to develop Use Cases.
• Created RUP activity diagrams and sequence diagrams to analyze the requirements and recommend solutions.
• Involved in the various aspects of project management - from resource planning to work flow and timeline management and in the process involved in learning the various facets of application of the Theory of Constraints to project management.
• Developed business process flow with UML and RUP methodologies/tools for work flow and use case diagrams.
• Created Mock-up forms in MS word for better visualization and understanding of the software solution.
• Involved in prepared the UML Use Cases using Rational Rose
• Played an active and lead role in gathering, analyzing, and writing business requirements.
• Provided key input in working with users in defining project and business and system requirements.
• Conducted JAD sessions between the end users and the development team.
• Providing the team with detailed business process models, data integration requirements and data mapping documentation
• Developed timelines for project delivery, and managed projects and resources to successful completion.
• Prepared and analysed AS-IS and TO-BE in the existing architecture and performed Gap Analysis.
• Assisted in building a business analysis process model using Rational Rose and Visio.
• Documented the Functional Specifications Document using UML.
• Assisted the PM in setting realistic project expectations, Gap Analysis, and in evaluating the impact of changes on the organization and plans accordingly.
• Developed test scenarios and implemented test plan. Tested the application and reported the bugs to the development team.
• Interacted with the Helpdesk team to investigate and resolve production issues.

Environment: Rational Rose and Requisite Pro, MS Visio, MS Office, MS Project, SAS, Agile, UML, XML, Windows XP, HTML, SQL Server, Crystal Report, SharePoint, Oracle 8i/9i/10g.

Confidential

QA Analyst

• Planned and designed MMIS business processes assisted in formulating recommendations to improve and support business activities Assisted in analyzing and documenting client's MMIS business requirements and processes. Also worked on Medicaid policy, interpreting Medicaid policy to provider case management staff to determine accurate utilization review decisions Responsibilities:
• Lead Business Intelligence reports development efforts by working closely with Microstrategy, Teradata, and ETL teams
• Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
• Documented Medicare claims processing.
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements
• Requirements Elicitation, Analysis, Communication, and Validation according to Six Sigma Standards.
• Improve operations and to streamline functionality of managed care plans, Fee-for-service providers, and Medicaid consumers.
• Involved in designing and implementation of Use Cases and Test Plans.
• Analyzed requirements for making the system compliant with HIPAA standards, Medicare eligibilities and benefits. Coordinated on work with claims and benefits configuration set-up involving Inbound/Outbound interfaces and ETL functions.
• Design, development, implementation and roll-out of Microstrategy Business Intelligence applications
• Performed gap analysis as pertains enrollment, membership management, Commissions, Finance and claims processing
• Resolved enrollment and termination issues as well as dependent additions.
• Involved in all phases of software development life cycle in RUP framework.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Managed the transition to new development standards, procedures and processes including the introduction of UML, Rational Products including Rational Software Architect, ClearCase and ClearQuest as well as the Mercury Test Suite
• Developed detailed Developer specification to reflect technical details of the business requirements
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases Test Scripts that are executed during testing process.
• Held several JAD and JAR sessions to facilitate interaction with Business Users.
• Conducted Gap Analysis on the AS-IS and TO-BE business processes.
• Configured and maintained medical products and benefits for large employer group releases, open enrollment annual benefit changes and healthcare reform changes.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Conducted JAD sessions to resolve critical issues
• Provided management support to the off-shore End to End Integration / Regression Test Team
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team
• Acted as a Subject Matter Expert on Application knowledge for preparing training presentation, Quick Reference Guides and assisting with any issues/questions that arose from training

Environment: Rational Suite Rose, Requisite Pro , PHP, Windows XP/NT, SharePoint, Oracle. MS SQL Server, XML, MS Office Word, Excel, Vision, Outlook, Excess , SharePoint, MS Visio, WinRunner, SAS, VBA Macros.

Confidential

Business Analyst

Confidential is nation's leading pharmacy benefits manager. Benefit Enrollment and Maintenance and Claims Processing is extensive HIPAA analysis and assessment project. It is aimed to provide HIPAA compliance to Medco's clients with ANSI x12 834, 835, 27x

Responsibilities:

• Created and submitted report specifications and system change requests, communicating with and training staff on modifications accordingly
• Interpreted and analyzed organization data and created report requests as needs were identified assisted in defining and implementing the use of data cubes throughout the organization
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Acted as a lead representative on work groups and Continuous Quality Improvement committees that evaluated data, managed outcomes and planned for the implementation of a quality improvement and performance based system
• Created specifications for EDI HL7 A28, A31, ADT and X12 837/835 transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers
• Validating the EDI 837 claim billing professional, institutional and dental claims 835 remittance advice or payment claims adjudications.
• Developed business process models in RUP to document existing and future business processes.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Created Need Analysis Documents of the requirements gathered through JAD and JRP individual elicitation sessions using MS Word
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology.
• Collaborated with Department Directors to develop and write Performance Improvement Projects according to Centers for Medicare and Medicaid Services CMS standards
• Prepared High Level Logical Data Models and BRD supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze and document business data requirements.
• Wrote SQL queries for each Test case and executed in SQL Plus to validate the data between Enterprise Data Warehousing and Data Mart Staging Tables.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Performed task decomposition, delegated tasks and monitored project milestones using MS Project.
• Created User Acceptance Test Plan and coordinated UAT for the site redesign project
• Responsible for executing Volume Testing, Compliance Testing, Data Quality Testing.
• Environment: Requisite Pro, Rational Rose, Agile, PL/SQL, HTML, MS Office Word, Excel, Vision, Outlook, Excess , EDI, UML.