SUMMARY

• 7+ years of extensive experience in Business Analysis, Software Validation and business process re - engineering.
• Functional experience with concentration on Use Case modeling using UML, Business Process Modeling, Data Modeling, Technical Training, Agile SCRUM and Waterfall methodologies, UAT and Systems Testing of client server, mainframes, and web-based systems.
• Extensive experience with Medical Claims Processing and Claim Adjudication process.
• Strong experience in Healthcare industry including HIPAA, PPACA, EDI, SOX, PHI, PII with emphasis on regulatory projects: conversion, ICD9 to ICD10 conversion, PPACA implementation.
• Very good experience with Medicare Advantage implementations.
• Experienced Joint Application Development (JAD) Facilitator and meetings coordinator with excellent communication and interpersonal skills.
• 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).
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules ofFacets.
• Knowledge in teh 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
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835 /271 transactions.
• Working noledge of EDI transaction sets 834, 835, 837 (P, D, me) 276, 277, 278, 270
• Experience in configuration of claims adjudication systems, FACETS 4.71/4.81/5.01.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Extensively used SQL scripts/queries for data verification at teh backend.
• Experienced in developing reporting application using ETL (Informatica) and Cognos Business Intelligence Suite with multiple data sources like Oracle, MS SQL and DB2 database.
• Experienced with Agile methodology: sprint planning, kanban method and writing user stores in RALLY.

TECHNICAL SKILLS

Methodologies: Waterfall, RUP, Agile SCRUM

Project Management: MS project, Lotus Quickr, Mantis

Healthcare tools: Claredi, Foresight Test Data Generator, Filezilla

Testing: Quality Center, QTP, JIRA, Sharepoint Defect Tracking

Language: C, C++, Java, .Net, UML, XML, HTML

Database: SQL Server, Oracle, MS Access, DB2, TOAD interface, MS SQL Server Management Studio

Reporting tools: Crystal report XI, SAS,COGNOS

Modeling Tools: MS Visio, Rational Rose

PROFESSIONAL EXPERIENCE

Confidential, Downers Grove, IL

Business Analyst

Responsibilities:

• Gathered requirements from stakeholders for provider management and member management.
• Modeled teh ‘as-is’ process flow and teh ‘to-be’ process flow and analyzed teh gap and developed teh action steps to fill teh gaps.
• Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Claim Processing and Subscriber/Member module.
• Responsible for teh full HIPAA compliance lifecycle life cycle from gap analysis, mapping, implementation and testing for processing of Medicaid and Medicare Claims.
• Conducted Risk analysis and developed mitigation plans.
• Conducted Impact analysis when there is any change in teh requirements and updated teh Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
• Developed teh User Interface (UI) prototypes to capture and validate requirements and spike solutions to teh current problem.
• Expertise in RDBMS concepts and running SQL queries.
• In depth noledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of teh training program to vendors.
• Designing Functional Specifications for teh target physical database.
• Developed UAT test cases associated with teh functional requirements.
• Maintained a weekly status report for teh requirements team and incorporated teh same to teh PMO status reports send to CMS.
• Analyze EDI - X12 data elements captured by teh existing system to validate it against teh data elements required for new system.
• Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
• Worked with BA Lead in reviewing teh System Change Documents (SCDs) to identify teh differences of IDX LIVE and IDX RM environment.
• Developed User Requirements for proposed HIPAA 5010 EDI transactions including 834 (Benefit Enrollment), 835 (Remittance Notification) and 837 (Claims Submission) Transactions.
• Generated difference reports based on pre-run and post-run AP reports.
• Regenerated report (if required) using IDX EDI Automation report regeneration tool.
• Converted HIPAA 835 and file format into flat file by using UltraEdit, EDI Environment Management Tool (EEMT), and dropping teh files on SeeBeyond.
• Produced member eligibility and valid provider extracts using Emdeon Office.
• Extensive data validation on teh back end using SQL queries to verify teh data has been loaded in teh correct tables.
• SQL output comparison between teh legacy process and teh modified 5010 process.
• Used SQL queries to validate teh load of teh data to teh correct column in an existing table and teh newly added tables.
• Ran files through HIPAA validate tool, Claredi to identify teh errors.
• Ran accept, reject, and pended cafes using IDX LIVE and IDX RM and used BeyondCompare to identify teh differences.
• Created ERAs and HIPAA 835 and HIPAA 837 Outbound files using EDI Queue Manager, and EDI EOB Run Manager.
• Closed teh runs for teh current Release and generated email, reports, and other necessary documents for teh upcoming Release.

Environment: Windows 2003/2010, Citrix, IDX LIVE, IDX RM, MS Office suite, MS Outlook, MS Visio, MS SQL Server, Facets,SharePoint, HP ALM, ClarEDI, Beyond Compare, See Beyond, UltraEdit, EDI Environment Management Tool

Confidential, Nashville, TN

Business Analyst

Responsibilities:

• Worked on Member Management, Eligibility, Claims, and Provider modules within FACETS.
• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, premium billing, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system to FACETS.
• Involved in Medicare Advantage implementation.
• Used MS SQL Manager Studio 2008 to query teh MS SQL database.
• Involved in documenting teh business process by identifying teh requirements and also involved in writing teh system requirements.
• Worked in creating interfaces for various external vendors and created Technical Specifications for teh 835 and 837 me and P files with their changed and new contents to create 5010 complaint files.
• Facilitated Joint Application Development (JAD) sessions with all IT group members for communicating & managing expectations and to discuss various means for integrations with current system using an adoption through execution strategy.
• Performed teh analysis of teh earlier systems, generated a detailed requirements document describing new system architecture through use cases diagrams and activity diagrams using MS Visio.
• Identified and documented teh requirements for 5010 conversion.
• Collected teh information related to ongoing application upgrade and their impact on ICD-10 implementation and impact, benefits and risks of ICD-10 code application.
• Re-Organized teh collected data and prepared documentation for implementation.
• Facilitated data mapping activities and halped with teh expansion of membership and provider data model.
• Created workflow diagrams, process flow and data flow diagrams. Assisted team with Data Mapping and Data Extracting Strategies for data migration.
• Involved in creating use case diagrams for teh purpose of teh team to understand teh workflow of teh system.
• Analyzing teh business needs for teh reports and documenting teh requirements in SSRS forms.
• Analyzed EDI ANSI X12 file mapping and reported in analysis spreadsheet. Performed validation of 837 (P, me) & 835 format files.
• TEMPEffectively communicated user acceptance test results between users and development team and provided recommendations for change control requests (CCR).

Environment: Facets, MS Visio, Word Excel, PowerPoint, Rational Rose, Requisite Pro, SQL. PEGA.

Confidential, Louisville, KY

Business Analyst

Responsibilities:

• Elicited requirement from teh business stakeholders and SME’s using various requirement-gathering Techniques.
• Created “As-Is” and “To-Be” process maps and conducted a gap analysis.
• Loaded different Medicare and Medicaid fee schedules for teh Providers and automate teh process using stored proc.
• Conducted iteration planning game to assign stories to Development Team and to teh Testing Team.
• Expert Knowledge in various Payer Fee Schedules and Provider Fee Schedules for Medicare and Medicaid.
• Involved in FACETS Implementation, involved end-to-end testing of FACETS Billing, Claim Processing and Subscriber/Member module.
• Elicit requirement to be able to generate teh tools and info needed to process teh ICD-10.
• Experiences working in ANSI x12 EDI Transaction.
• Work on coordination of benefits (COB) in a claim processing.
• Used to execute test cases for several transactions such as 837, 835, 820, 834, 277, 278, 270/271
• Experience in working with a Provider portal for claims where teh rendering providers provide claims for teh service Rendered.
• Experience in working with Referrals sent in via fax by teh Referring Providers.
• Experience in conducting User Acceptance Testing (UAT) and documenting teh UAT issue log.
• Created User acceptance test checklist (Scope, entrance criteria, test case, test scripts, test execution, test data, defect management, test results, UAT test exit criteria)
• Conducted GAP analysis and filling gap according to teh format set by HIPAA.
• Wrote test cases in Quality Center derived from teh Design documents and generated a Traceability Matrix for testing purposes.
• Created Traceability Matrix to ensure implementation of all functionalities, identify all test conditions and test data needs.
• Used Quality Center to record documenting information useful in debugging process, evaluating test data.
• Extensively worked on any requirement upgrade and/or change request while doing UAT.
• Worked closely with development team to ensure teh application performance and stability and also ensure teh application completes teh whole end-to-end process.

Environment: Agile/Waterfall, MS Visio, FACETS HP QTP, Oracle, Windows 2000, Quality Center, JAVA, SQL, Facets and MS Office Suite.

Confidential, Omaha, NE

Business Analyst

Responsibilities:

• Created Use Cases dat defined teh role of users who receive claims, users who process claims and users who adjudicate claims. Used MS Visio to develop UML diagrams Validate EDI Claim Process according to HIPAA compliance.
• Coordinated and facilitated extensive Product Owner interviews to gather and analyze requirements.
• Translatedbusinessuser concepts and ideas into comprehensivebusinessrequirements and design documents.
• Successfully usedAgile/Scrum Method for gathering requirements. Documented User Stories and facilitated Story Point discussions to analyze teh level of effort on project specifications.
• Created Prioritized Product Backlog, Sprint Backlog and managed User stories for Current and subsequent releases using RALLY.
• Developed High Level and Detailed Process flow diagrams forBusinessprocess of UI Wireframes and Mockups using Microsoft Visio.
• Conducted meticulous GAP analysis while successfully reengineering keybusinessprocesses to increase operational efficiency and alignment ofbusinessunit objectives
• Created Test cases and tested teh user stories for accuracy and compliance to ensure undisputed acceptance and validation of stories.
• Created Requirement Traceability Matrix (RTM) to make sure teh current project requirements are being met.
• Provided specifications for developers and QA through acceptance tests and requirements.
• Facilitated and participated in Scrum ceremonies (Pre-Planning, sprint planning, retrospectives, daily stand-ups, etc.)
• Involve in testing of FACETS Implementation, involved in end to end testing of FACETS Claims Processing module, Membership and benefits.
• Performed SWOT and Gap analysis for teh new functionality requirements Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with teh client and teh Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Responsible for validating claim processing transaction of MMIS.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Use HIPAA transactions to interface with Third-Party Administrators (TPA) also various proprietary file interfaces for TPAs not supporting HIPAA transactions.
• Develophealth and welfare fund and/or TPA to administer all member benefitsand payment
• Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry (270).
• Tested EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Understood teh state's electronic Medicaid eligibility verification system & teh Medicaid & Medicare welfare system intermediary along with their roles in claim processing.
• Identified and documented teh dependencies between teh business processes.
• Responsible for Medicaid Claims Resolution/Reimbursement for state healthcare plan using MMIS.
• Responsible for checking NPI and approval of claim payment.
• Conducted JAD sessions and Data modeling using UML.
• Worked with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.

Environment: SQL, MS Word, Excel, EDI, SQL, ACCESS, Lotus Notes, File Viewer, Web Client, Quality Center, MS Visio, SharePoint