PROFESSIONAL SUMMARY:

• Over 7 years of experience in the field of Information Technology in the Healthcare-Life Sciences / Pharmaceutical / Pharmacy Benefit Management PBM / Insurance domain encompassing business systems planning, procedural development, reporting and validation.
• Experienced in Requirement Gathering, Systems Planning, Procedural Development Implementation, Business Process Mapping, Problem Solving/Workarounds and Business Contingency Planning/Disaster Recovery, Creation of Domain Models and Creating Reports for Analytics.
• 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 and Requirement Traceability Matrix RTM across the deliverables of a project. Hands on experience in all phases of Data Modeling - Conceptual, Logical and Physical modeling. Experience in data transformation, data mapping from source to target database schemas, data cleansing procedures.
• Experience in Business Systems Analyst, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare.
• Knowledge of 837, 835, 277, 270, 271, NCPDP, 4010, 5010 and ICD-9/ICD-10.
• Experience with TriZetto Facets 4.31/4.51 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Defined Functional Test Cases, documented, executed test script in Facets system.
• Excellent knowledge of HIPAA standards, EDI Electronic data interchange Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Understanding and mapping of the various ICD9/ICD10 Codes applicable for tracking of diseases for which diagnostic testing is done in the area of BioChemistry.
• Worked with a tool set for creating crosswalk mapping rules and business rules to convert ICD-9 to ICD-10. Utilized CMS GEMs General Equivalency Mapping crosswalk mapping file.
• Knowledge and experience in implementation of HIPAA and NCPDP standards.
• Designed High level design, for New process, integrating with legacy and Facets
• Experience in preparing documentation which is in compliance with 21 CFR Part 11, Medicare Part D requirements, HIPAA ANSI X12 Transaction sets, and in accordance with NCPDP National Council for Prescription Drug Programs Standards. Experience in writing SQL queries and optimizing the queries in Sybase, Oracle and SQL Server.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Experience in GUI design using HTML, JavaScript, VB 6.0 and ASP.NET2.0 Web Controls.
• Worked as in a team with Account Management, Company Management to document requirements, process flows, wire frames, for corporate accounts/external clients.
• Application of Software Development Life Cycle SDLC , with thorough understanding of various phases such as Requirements, Analysis/Design, Development, Testing and Implementation.
• Extensive experience with Business Use Cases, Functional Use Cases, Business Process Models, Test Cases.Extensive experience in process modeling using UML, flowcharts, sequence diagrams, activity and diagrams.
• Strong knowledge of UML, RUP, Rational Suite including Rational Rose Requisite Pro, Clear Quest and Clear Case, Microsoft Visio.
• Functional experience with concentration on Use Case modeling using UML, Business Process Modeling, Data Modeling, Change Management, Technical Training, Software Development methodologies, QA testing, and Systems Testing of client server and web-based systems.
• Experience working with Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system, and conversion of ICD-9 to ICD-10.
• Experienced in conducting Joint Application Development JAD sessions with SMEs, Business Analysts, Software Developers and Quality Assurance teams for New Corporate Accounts or Clients.
• Experienced in Quality Assurance and testing of Client Server and Web based Applications.
• Excellent communication, interpersonal, analytical skills and strong ability to perform as part of a team in for four years in CMMI accredited and CMS Compliant Medicare Part D companies.
• Worked with ETL Developers and Process Analysts in preparing the requirements data and functional , and writing documenting work flows and process flows
• Understanding of the Lab Requirements mandated by the College of American Pathologists
• Strong attention to detail and proficient in working in high pressure environments with tight deadlines
• Experience with Data Warehousing and Business Intelligence Tools like Informatica, Business Objects, Broadcast Agent, and Web Intelligence
• Experience with conducting assessments and impact/gap analysis concerning State MMIS

TECHNICAL SKILLS:

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Business Analyst

Medco applications, systems and process needed to be in compliance with and be able to support the HIPAA transaction standards. As a part of program delivery team I was responsible to coordinate and lead a suite of projects on claims domain to coordinate and gather requirements for Medicare Prescription Claim Adjudication System called POS Point of Sale . Claims include Mail claims, online claims and paper claims which coordinated with multiple backend systems, resulting in increase of automation rate of the claims. The scope of this project is planning, analysis, design, development and implementation required to implement the mandated HIPAA NCPDP Versions D.0 from 5.1 and 3.0 electronic transaction standards. Worked towards gathering requirements for enhancements to the Mainframe Claim Engine for various Business Areas like Claims, Enrollment, eligibility and Plan.

Responsibilities:

• Conducted meetings to gather requirements from Business Owner, Stakeholders and Subject Matter experts to capture high-level scope Epic of the Project.
• Facilitated daily stand ups and managed task board with the project team.
• Utilized Agile Scrum to configure and develop processes, standards, and procedures and
• to perform System analysis
• Lead joint application development JAD sessions with project team to capture and elicit the requirement to prepare business requirement documents BRD and functional requirements documents FRD .
• Created requirements models such as UML activity diagrams and business process maps to depict the contextual view of the requirements.
• Conducted structural walkthrough sessions with project team and project sponsor to obtain approval on final documents
• Interacted with different departments like claims and technical teams regarding the performance issues related to claims processing system.
• Worked closely with the project team in support of problem solving and as the needs of the project dictates.
• Supported impact analysis effort to identify impacted functional area and possible trend break.
• Extensive involved in Medicare Part D, PPO, HMO, diagnostic codes, and claim processes.
• Worked on the Mixed Code Claims and Description issues related to the ICD-9 ICD-10.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the Business and Policies rule and regulations.
• Conducted data analysis using SQL Scripts to answer the questions/ queries by the Subject Matter Experts.
• Perform excel functions and formulas including Vlookups, Conditions for data analysis.
• Wrote access queries on vast amount of data generated from multiple sources.
• Performed access queries including retrieves data, tables, joins, extract, creates, and analyzes to presents reports and data crosswalk from database
• Performed access queries including retrieves data, tables, joins, extract, creates, and analyzes to presents reports from database.
• Involved in the technical specifications of related functional requirements documents prepared by the project team.
• Worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan and reported and documented any issues occurred during UAT.

Environment: Win 2003, MS Office, JAD, Use Cases, SQL, UAT, Quality Centre, Requisite Pro,

MS Project, Activity Diagrams, UML, Test Cases, Agile, Data modeling Visio , optimal trace and Caliber RM.

Confidential

Business Analyst

The project was to develop Claims record system to validate patient demographics and verify insurance claims eligibility in real time. The features of this project included Medicare/ Medicaid Eligibility and Billing Verification, Self-Pay/Commercial Eligibility and Billing Validation, Real Time Processing, Billing Address Verification with Address History and Insurance Eligibility Verification.

Responsibilities:

• Understanding and assessment of the current EDI Transactions used
• Understanding and assessment of the current Pharmacy Transactions from an NCPDP 5.1 perspective
• Maintained Traceability matrix throughout the project.
• Created standards / guidelines for business process modeling, Use Cases, Work Flows, Data Dictionary, and Requirements specifications.
• Mentoring end-users on requirements specifications techniques and the software development life cycle.
• Assisted with building the EDI 837 I, D, P , 835, 277-U, 270/271, 276/277, 278, 820 and 834 transactions processing flow from the Trading Partners to the translator to the Mainframe and back to the Trading Partner.
• Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837- I, P, D , 835 Remittances and others. Resource for UB92 and HCFA1500 billing format, transaction sets requirements, EDI development and Design, X12 protocols through Version 4010 A1 and newer, conversion needs and understanding of legacy EDI formats, such as UB92 Versions 4, 5, 6 and NSF.
• Gathered and analyzed requirement for ICD 9 to ICD 10 changes
• Involved in up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM Clinical modification to ICD-10-CM/PCS Clinical modification/procedure coding system simultaneously.
• Presented power point presentations to clients and Stake holders.
• Knowledge of industry billing and coding compliance requirements
• Converted the Business Process Requirements BPR into System Specification Requirements
• Created various Use Cases and workflow diagrams, sequence diagrams, and Class diagrams using MS Visio and used UML methodology to define the Data Flow Diagrams DFD
• Maintained Traceability Matrix in Excel
• Used IBM Rational ClearQuest as Version Control/Change Management Tools
• Created requirements analysis and design phase artifacts using Requisite Pro and MS Visio

Environment: MS Office Suite, MMIS, POS, GEMS, Document Analyzer, Sharepoint, XML

Confidential

Business Systems Analyst

Confidential is an implementation company catering to the State Department of Medicaid. As a Business Analyst and a part of the gap analysis and implementation team, the role is to understand the EDI Transactions, Pharmacy Transactions from an NCPDP perspective and current ICD9 codes being used by the State. The objective is to conduct a gap/impact analysis in order to adhere to HIPAA Compliances required by CMS for the years 2012 and 2013. The duties performed for this role are as follow:

Responsibilities:

• Networked with Subject Matter Experts, Project Manager, Developers, and Process Analysts to understand the business process, gathered Business Requirements and identified enhancements.
• Extensively developed project documentation, process flow documents, formal proposals, RFQ's and RFP's. Formulated methodologies and developed SDLC phases, strategies, time cost estimates with milestones for each phase.
• Prepared Business Requirement Documents BRD's after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Participated in project meetings to support the team as required, Organized various meeting with SME's and testing Team to ensure that we are on track with all of our deliverables, tracked all our deliverables on a daily basis by using Deliverables tracking Template. Teamed up with both internal and external software development teams to provide functional requirements specifications in the form of use cases, business process flows, and prototypes and management reporting requirements.
• Designed Data Flow Diagrams DFD's , Entity Relationship Diagrams ERD's , and web page mock ups using modeling tools. Involved in formatting data stores and generate UML diagrams of logical and physical data. Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Understanding and assessment of the current EDI Transactions used. Understanding and assessment of the current Pharmacy Transactions from an NCPDP 5.1 perspective. Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data. Worked in mainframe environment and used SQL to query various reporting databases.
• Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system.
• Understanding and assessment of the current ICD 9 codes used by the State
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions 837, 835, 276/277, 270/271
• Creation of a Gap/Impact Analysis Document for changes to Pharmacy Transactions real time and batch based on NCPDP 5.1 to NCPDP D.0 , specifically concerning the data elements
• Creation of a Mapping Document for ICD9 Codes to ICD 10 Clinical Modifications and Procedural Codes.
• Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System
• Creation of Gap/Impact Analysis Document Operational Analysis Document for the Drug Utilization Review System
• Creation of Gap/Impact Analysis and Operational Analysis Document for Medicaid Subrogation
• Creation of Gap/Impact Analysis Document and Operational Analysis Document for the Drug Rebate Analysis and Management System
• Participated in implementation and understanding of Claims- based EHR. Coordinated, participated and provided guidance to the QA team at every phase of testing performing Phase and Unit testing, System testing and User Acceptance testing.

Environment: MS Office Suite, MMIS, POS, GEMS, Document Analyzer, SharePoint, MS-Visio, MS Excel, MS Access, Mainframe, ETL, UML, Rational Requisite Pro, Rational Rose, Rational Clear Case, Rational Clear Quest, html, JAVA, Asp, MS Window Server.

Confidential

Business System Analyst

Confidential is a Non-profit organization providing health benefits to the residents of Massachusetts. I Worked for the team that is responsible for receiving, documenting, processing the 837 transactions upgraded as per with EDI X12 ICD 9- ICD 10 and 4010 to 5010 version of HIPAA.4010A to 5010A and the new 277 Claims Acknowledge transaction into the Medicaid Management Information System MMIS . The design includes the documentations of the Paper Claim Entry, Electronic Claim Entry, Daily ECA Reporting, Electronic Claim Acknowledgement, Weekly ECA Reporting and Data Mapping from ICD9 - ICD 10. Each area includes a description and flow for the current processing and a design for the changes necessary to implement the HIPAA 5010 and NPI mandates including identification of issues, impacts and risks, and a contingency plan in the event the design cannot be implemented or other issues exist which prevent the functionality from being implemented.

Responsibilities:

• Conducted JAD session's workflow diagrams, UML diagrams, process models, activity diagrams, use cases, for incorporating design changes in the order creation/ management system.
• Clearly understood coding standards required for all Medicaid Users transactions involving electronic data interchange as provided by department of health and human services and incorporated at every stages of the project wherever found necessary.
• Prepared the Business requirement Document BRD and functional requirement document FRD for the enhancement of the existing services.
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Performed data analysis, created data mapping and data interface documents and kept the documents updated with changes in requirements and functional specifications.
• Experienced with business intelligence tools such as Cognos products, Crystal Reports
• Applied a structured change management approach and methodology for the people side of change caused by the respective projects and change efforts.
• Worked on developing the business requirements and use cases for automating the billing entity and commission process.
• Created UI mock up and functional specification.
• Gap analysis for HIPAA 4010 837P transactions and HIPAA 5010 837P transactions.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems
• Performed access queries including retrieves data, tables, joins, extract, creates, and analyzes to presents reports and data crosswalk from database.
• Perform excel functions and formulas including Vlookups, Conditions, concatenate, substring and other formulas for data analysis.
• Created mapping table for the Transactions accepted by the Sybase translator move into an Interface Database for 837 transactions.
• Coordinated with data architects and ETL team to understand/drill down on the data mart requirements.
• Designed strategy for up gradation of system and implementing User interfaces UI to be 5010 compliant.

Environment: MS Office, MS Visio, Rational Requisite Pro, ICD-10, ICD-9, HIPAA 4010, 5010, GUI, Test Director, Agile Scrum, BPR, XML, UAT, and Sql Server 2008.