SUMMARY

• Over 7+ years experience in Healthcare Industry and Depth Knowledge in HIPAA compliance, Electronic Data Interchange (EDI), implementation of HIPAA code sets, ICD - 9 and ICD-10.
• Thorough understanding and hands-on working experience with standards of EDI and having Knowledge of various methodologies including Agile/Scrum.
• Highly skilled in identifying system and client needs. Detail-oriented, excellent analytical, communication and interpersonal skills.
• Developing and improving client relationships through effective project and operational support for Interchange MMIS Accounts.
• A hard-working team player with extensive knowledge of SDLC, Gap analysis, JAD session, UML model and UAT.
• Created a robust share point site as a central repository for excel spreadsheets to aid efficiencies within a virtual workgroup and assist team members with access to data.
• Experience in Forward Mapping and analysis of ICD 9 - ICD 10 Conversion, for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Skilled in gathering and analysis of business requirements for software applications from functional and project management perspectives.
• Worked on 837 (I, P, D), 834, 835, 820, 270, 271, 276, 277, 278 transactions and BRCs of the transactions.
• Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.
• Implemented various HIPAA codes (270 and 276) used for Billing and Eligibility purposes of patient records.
• Experience in writing SQL queries/joins for Oracle and SQL Server databases.
• Expertise in Data analysis, Data research / mining from various data sources.
• Involved in analyzing and documenting reports, report models and end user report builder usage.
• Worked on documenting various reports such as ad-hoc reports, drill-down, drill-through, and parameterized reports. Developer report templates using iRise.
• Comprehensive knowledge of Software Development Life Cycle (SDLC), having thorough understanding of various phases like Requirements, Analysis/Design, Development and Testing.
• Exposure in Forward Mapping and Backward Mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).Have exposure to EDI, Web Portal, DSS and System documentation.
• Experience in conducting UAT (User Acceptance Testing) and documentation of test cases, ability to communicate both on a business and technical level and experience in coordination with business and technical resource.
• Good control on MS Office suite, MS Visio and MS Project. Excellent documentation, communication and interpersonal skills.
• Adept at creating and transforming business requirements into functional requirements and designing business models using UML diagrams - Context, Use Case, Sequence, Activity diagrams in MS Visio and Rational Rose.
• Organized many Joint Application Developments (JAD) sessions, scrum meetings and Joint Requirement Planning sessions (JRP), walkthrough, Interviews, Workshops and Rapid Application Development (RAD) sessions with end-user/clients/stake holders and the IT group
• Excellent presentation skills with MS Power Point, which was extensively used in different JAD sessions and to track progress. Communication ability with prospective vendors.
• Assisted the project manager with activities like development of business processes, effort estimation, resource management, issue/risk analysis, milestone tracking and associated documentation
• Comprehensive knowledge of RUP, Agile, Scrum, FDD, Waterfall Methodologies.
• Excellent track record for meeting deadlines and submitting deliverables on time.

TECHNICAL SKILLS

Software: MS Office Suite(Word, Excel, Access, PowerPoint & Outlook), MS Visio, EDI, HIPAA, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Programming Languages: C, C++, XML, SQL.

Database: Oracle, DB2, Teradata, MS SQL Server

Reporting Tools: Crystal Reports 8.0, SSRS, SSAS, SSIS

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, UNIX, LINUX

Methodologies: Agile,UML, SDLC, Scrum

Mainframe: COBOL, DB2, JCL, CICS, MVS

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

PROFESSIONAL EXPERIENCE

Business Analyst

Confidential - Denver,CO

Responsibilities:

• Running usability of testing for readiness, and create procedural manual based on the need of the client.
• Audit claim billing product plan code via manual from US mail or electronic using payment data forms and practice management systems, Manufacturing processes and procedures Resolved rejected claims.
• Analyze employer group information to identify commercial, government and self-funded claims.
• Advanced understanding of medical benefit HMO, PPO networks, Medicaid and Medicare plans.
• Extensive training with Medical terminology, CPT, REV UBE84, and HEFA claim forms.
• Extensive experience and research, verbal and written communication, for claim inquiries for plans and staff Understanding of regulation statutory guidelines, HIPAA and the Affordable Health Care Act.
• Effectively applied Scrum /Agile methodologies and enforcing project standards using Rally tool.
• Used Business connectivity services to display data in share point site from external source.
• Worked on migrated some Crystal reports to SSRS reports.
• Created lists of ICD9 - ICD10 CM/PCS codes, with reference to the usage percentile and provided to Stakeholders to determine if codes were best fit or all possibilities.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Medicare/Medicaid claims processing in compliance with government compliant processes such as HIPAA/ EDI formats and accredited standards.
• Lead the project team in the analysis, design scheduling, construction, and delivery of a new Medicaid Management Information System (MMIS).
• Met weekly with the Project team and the client to review and discuss the data in the reports produced that detailed the progress of the MMIS Implementation.
• Oversee and direct the daily activities of the regional market EDI department to keep day to day operations running smoothly.
• Manage Medicare Advantage EDI encounters from IPA (Independent Practice Association) and Providers.
• Proficient in Quality Assurance Life Cycle like developing Test Strategies, Test Plans, Test Cases (Manual/Automated), Defect Reports and developing Test Scripts.
• Strong experience in conducting UAT and documentation of test cases.Effectively applied Scrum /Agile methodologies and enforcing project standards using Rally tool.
• Make customized changes to the MMIS per state guidelines and client request.Managed security access into MMIS for clients as well as staff.
• Electronic Data Interchange (EDI) software and supported clearinghouses. Receive, research, and resolve customer .
• Adhered data transition of the Claim Status and Eligibility as per the EDI standard.
• Developed an implementation guide for Partners for EDI X12 837p transactions and Assisted in the design of EDI solutions and represented Enterprise EDI team with regards to EDI/XML industry standards.
• Worked on data architecture, metadata, design goals of ER modeling for OLTP and dimension modeling for OLAP designs, creates and processes cubes using SSAS
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Designs, creates and processes cubes using SSAS.
• Worked on developing SSIS Packages to Extract, Transform and Load (ETL) data into the Data warehouse from heterogeneous databases such as Oracle 11g and 9i, DB2.
• Worked on using complex formulas and to query the database to generate different types of ad-hoc reports using SSRS.
• Created new security reports and maintained other security reports within MMIS system.
• Manages the system security and role privilege matrix requirements in MMIS System.
• Worked with data mapping team for ICD 9 to ICD10 for forward mapping of the diagnosis and procedure codes.
• Worked on SSAS storage and partitions, and Aggregations, calculation of queries, Data Mining Models, developing reports using SQL.
• Participating in Agile Scrum process and using Rally to update the status of allocating tasks list and analyzed the processes in medical coding and transition from ICD 9 to ICD 10.
• Worked on the designed SSIS Packages to transfer data from flat files to SQL Server using Business Intelligence Development Studio.

Business Analyst

Confidential -Milwaukee, WI

Responsibilities:

• Involved in gathering Business Requirements from State, Users and Internal Offices.
• Analyzed the client's applications to determine the impact of the Enhancements on EDI Transactions Set and Code List implementation and defined the changes to bring the affected systems into compliance.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions. Interacted with Claims, Payments and Enrollment teams, hence analyzing and documenting related business processes.
• Analyzed legacy systems, file and record formats, system flow charts and other information to develop a comprehensive depiction of the existing environment. Developed Business Crosswalks for 837 I/P, 835, 270/271 and 276/277 transactions per CMS - HIPAA implementation rules.
• Organized and hosted JAD sessions to identify the business flows and determine the impact on current and proposed systems.
• Involved in performance testing of Medicaid client server claims processing system, Medicaid MCC / MCO and Medicaid Management Information System (MMIS)
• From payers perspective (MMIS) all transactions are made compliant to ANSI ASC 4010A1 X12N standards to talk with various Legacy system.
• Produced Gap Analysis documents for both HIPAA 5010 and ICD-10 Enhancements.
• Worked on EDI transactions, submitting and tracking claims until adjudication and Remittance Advice.
• Experienced creating and submitting Claims including Paper, Electronic/Online/Batch, Real-Time and POSL.
• Created TARs (Transaction Authorization Request) including Paper, Electronic and Pharmacy, for all Claim types and Transactions.
• Worked closely with multiple teams to improve the overall reporting of the Claims, payments, Real-time adjudication information.
• Developed test cases based on the crosswalks and compliance guidelines for 837 Professional and Institutional claims and for 270/271 Eligibility inquiry and response.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Created Technical specifications for the Business Objects Reporting Applications.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, Object Oriented Design (OOD).
• Experience in Forward Mapping and analysis of ICD 9 - ICD 10 Conversion, for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Actively worked with quality control teams to develop test plans and test cases.
• Developed tables, Views, Stored Procedures and Triggers using SQL Scripting.
• Worked closely with the overall project team in planning, coordinating and implementing QA methodology on various phases of project.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Analyzed results of System and Regression Testing performed by Test team and held meetings with Client and Management for Deliverable Approvals, Project closure and Sign off.
• Supervised, trained, and supported quality work ethics.Understanding of the complicate health care cycle contact customers on questions regarding claims to assure policy processing deadlines.
• Analyze accuracy of ICD-9 and HCPCS Codes used to submit claims for payment against the reimbursement on the explanation of benefits (EOB) and coordination of benefits (COB).
• Verified for correct codes and bundling rules used for claims and that payment were reimbursed in accordance with billing and coding guidelines.
• Involved in gathering and analysis of business requirements for software applications from functional and project management perspectives.
• Created and transformed business requirements into functional and non-functional requirements and designing business models using UML diagrams including Use Case diagram, Activity diagram,Class diagram,Sequence diagram in MS Visio,Requirement Traceability Matrix (RTM), Training and User Manuals.
• Proficient in Quality Assurance Life Cycle like developing Test Strategies, Test Plans, Test Cases (Manual/Automated), Defect Reports and developing Test Scripts.
• ICD-9 and new plan implementation, interface with clients to understand their needs and configuring software to meet those needs.

Business Analyst

Confidential -Irving, Texas

Responsibilities:

• Reviewing and correcting rejection claims,Assist with month end balancing and closing.Analyze employer group information to identify commercial, government and self-funded claims.Created MS Access databases and wrote SQL queries for data manipulation.
• Understanding of credentialing process and process payers enrollment for EDI submission.Familiar with HIPAA EDI transactions such as 835,276, 277, 278 etc.
• General Bookkeeping, Patient Registration, Medical Insurance Forms & Authorization, Firm Knowledge in CPT& ICD9.
• Works on processing MMIS monthly files and creates necessary reports for the Users.
• Loads/Verifies insurance coverage. Knowledge of CPT and ICD9 Codes.
• Work on 834 and 835 projects, including syntax and business rules for X12 HIPAA 4010 validation for loops, segments, elements, qualifiers and code sets. Create export and XML processes for Lotus Notes. Create EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors.
• Analyzed the security implementation of the application with respect to users perspective.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Documented the business requirements into high-level requirements document.
• Gathered the requirements and transformed them into high-level Process-Flow Diagram using PowerPoint.
• Involved in Managing Data modeling project from Logical design and implementation of Sybase Database.
• Identified source systems, their connectivity, related tables and fields and ensure data suitably for mapping.
• Performed extensive requirement analysis including data analysis and gap analysis.
• Worked on project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Created Error Files and Log Tables containing data with discrepancies to analyze and re-process the data.
• Developed business process models in RUP to document existing and future business processes.
• Troubleshot the designed jobs using the Data Stage Debugger.
• Created a task plan for the team identifying the key deliverables and the respective deadlines.
• Supported users with word processing, spreadsheets, relational databases and presentation software. Created and developed the TO-BE system presentations using PowerPoint.
• Experience in monitoring claim rejections, verifying and obtaining carrier requirements for claims submission,researching payer rejections and resolving filing issues.
• Executing and implementing and auditing to ensure accurate and timely payment to health care providers accordance to client plan specifications set for commercial and federal plans.
• Understanding of business functions and ability to understand system interfaces.
• Sort HCFA's to proper carriers,Print and distribute paperwork daily & Pull weekly reports and closed companies daily. 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.
• Excellent organizational, verbal and written skills to understand interpret and communicate ideas, including the ability to succinctly present the results of their own analysis utilizing Microsoft PowerPoint or similar tool.