SUMMARY

• Over 7 years of Business Analysis experience with superior performance in application development projects, implementations and improvements of business processes. Possess large spectrum of experience in dealing with the Healthcare industry.
• Proficient in Requirement Management, including gathering, analyzing, detailing and tracking requirements
• Experienced in documenting requirement using Unified Modeling Language Use Case and Activity Diagrams . Also building business Process Flow, Context Diagrams, Sequence Diagram, Activity Diagrams, Class Diagrams using Rational tools and Microsoft Visio
• Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them
• Experienced in interacting with business users to identify their needs, gathering requirements and authoring Business Requirement Documents BRD , Functional Requirement Document FRD and Software Requirement Specification SRS across the deliverable of a project
• Strong Knowledge with Iterative approach for Software Development as per Rational Unified Process RUP . Involved in inception, elaboration, construction transition phases using rational tools like Requisite Pro, Clear Case, and Clear Quest during various phases of RUP
• Experienced in SWOT Analysis, Gap Analysis, Impact Analysis, Risk Analysis, and Project Planning
• Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process
• Exceptional Problem Solving and Sound Decision Making capabilities, along with the ability to resolve difficult situations
• Possess a detail-oriented nature with excellent communication, interpersonal skills, and recognized for being a valued team player
• Outstanding organizational skills including ability to multi-task, prioritize and manage increasingly complex issues.
• Good understanding of using testing tools, such as QTP and QualityCenter and performing a variety of software testing including User Acceptance, Performance, Load, Stress, Sanity, Parallel, Black Box, Grey Box, White Box, Positive, and Negative Testing
• Well experienced in working on MS Word, MS PowerPoint, MS Excel, MS Visio and MS Project
• Excellent verbal , written, interpersonal and communication skills with strong analytical abilities to perform well both independently and as a team player
• Proficient in working with project management tools like MS Project for status reporting and planning.
• Experience in Conversion of HIPAA X12 4010 codes to X12 5010 codes and ICD 9 codes to ICD 10 codes
• Extensive experience in claims processing and billing, Medicare/Medicaid billing and claims management including Medicare Part A, B, C, D , /Medicaid, Trizetto Facets, MMIS Medicaid Management Information System , HL7, HIX Health Insurance Exchange .
• Knowledge of HIPAA and various transaction codes like 270/271 inquiry/health care benefits , 276/277 Claim Status , 834 Benefit Enrollment , 837 Health Care Claim , 835 Payment/Explanation of benefits PPACA Health Care Reform and patient Protection and Affordable Care act .

Skill Set:

Projects Summary:

Confidential

Business Systems Analyst

Confidential covers many medically necessary services from health providers who participate in the Confidential program. The Medicaid Management Information System of DHHS is a 30 year old legacy system which processes payments for covered medical services for eligible Texans. The MMIS Legacy team handles all Business Analysis functions required to modify and enhance the current Medicaid Management Information System MMIS to meet State and Federal requirements. The scope of the project was to identify the areas impacted by the transition from ICD-9 to ICD-10 for different subsystems of MMIS. Worked on various subsystems Provider, Member, Managed Care, TPL-Third Party Liability, Claims, And Prior Authorization in MMIS.

Responsibilities:

• Conducted impact assessment sessions along with the project team to identify impacted functional area by ICD-10 implementation project.
• Conducted Planning sessions with Project Team, Sponsor, SMEs, and developers to build high level project scope.
• Conducted Joint Requirement Gathering session along with the project team to capture ICD-9 to ICD-10 Code conversion rules.
• Defined ICD-9 to ICD 10 mapping process using GEMs General Equivalency Mapping crosswalk file.
• Defined project milestones, schedules and was involved in monitoring progress and updating project plan using MS Project.
• Identified and documented issues, risks, gaps and their impact to the project life cycle.
• Worked as a SME and also served as a primary liaison between the business clients and
• Managed Care Organizations in developing final requirements for the project.
• Worked on the 834 initial enrollment, maintenance and audit transactions to keep the Managed Care Organizations updated on the client enrollment information and changes.
• Involved in testing and validating newly released Sybase HIPAA Accelerator Compliance maps.
• Worked on the 820 transactions to send the premium payment data to the Managed Care Plans.
• Involved in creating and updating Companion Guides, developing Business Requirement Documents, Functional Design Specifications, Impact Analysis Document, Crosswalks and Spreadsheets.
• Worked on several functional areas of MMIS claims processing unit and EDI for transfer of data between organizations by electronic means.
• Identified the scope, business objective and documented the functional requirements for each release.
• Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
• Performed functional testing, regression testing and User Acceptance Testing.
• Assisted in project management activities like planning, development, task allocation, project execution.

Environment: Rational Requisite Pro, Rational Rose, Rational ClearQuest, Rational TestManager, RUP, UML, SQL, MS Office, MS-Project, MS Visio

Confidential

Business Analyst

Confidential is a nonprofit health plan serving the Western Confidential. It also operates Univera Confidential is a part of Univera which supports Medicaid and Childcare plans. Project required reengineering of proprietary online application for business user to track the reconciliation process of each plan sponsor to approve, stop, and to redo the process from any process step of the reconciliation process. This also allowed the business user to view and maintain some of the key tables in the database. The project also involved migration from Diamond software to Facets including configurations, claims, auto adjudication scope and definitions, financial transactions ID cards and Membership as per HIPAA

Responsibilities:-

• Served as a mentor and provided orientation to new BAs on HIPAA claim transactions such as 837 P I and outbound transactions such as 277CA, ECA and 999.
• Created and updated test cases according to the new HIPAA 5010 standards for Transactions 837-I and P.
• Documented organizational policies and procedures in the context of system requirements.
• Facilitated meeting discussions between end users, Business analysts and Technical analysts.
• Understood and analyzed differences between 4010 and 5010 formats for all segments, elements, loops of 837-I and 837-P.
• Used SQL for data mapping and querying.
• Co-coordinated the UAT with the SME's to make sure that all the Business Requirements are addressed in the application.
• Performed Functional and GUI Testing to ensure that the user acceptance criteria are met.
• Created UML class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives.
• Planned RUP iterations and documented the artifacts throughout the various phases of the development process.
• Worked on System Change Requests and transformed them into Business Requirement Document BRD .
• Identified and validated business rules and data elements.
• Conducted workflow, process diagram and gap analysis to derive requirements for existing systems enhancements
• Conducted joint discussion sessions with business users, stakeholders to understand the requirements in more detail
• Responsible for creating business work flows and processes and creating management reports based on the analysis.
• Complete knowledge of different MMIS databases like Provider Databases, Recipient Databases, and Payee Databases etc.

Environment:- MS Office, MS Visio, Unix, SQL Server, SQL Developer, XML,, Facets, Rational Requisite Pro, Rational Rose.

Business System Analyst

Project Description:

Using the internet as a tool, e-Cleveland Clinic provides online billing system including modules like Patient Data capture , Charge capture and Checkout, Medicare and Medicaid Claims, Reports and Management, patients online second opinions, health news and complete health charts regardless of their location, eliminating the time and expense of travel. Medtronic products were used by physicians such as diagnostic equipment. It combines the patient data module, doctor-patient live chat system, patient surveys, web appointments and health insurance validation modules.

Responsibilities:

• Created complete test cases of varying complexity, executing tests, measuring expected and actual results, and reported status ensuring accurate coverage of requirements
• Set up test requirements, developed test plans, and documented manual test cases using QualityCenter requirements module.
• Assisted staff by sitting with patients, answering call lights, obtaining funeral arrangement information from families and delivering/restocking supplies.
• Managed all types of functional change requests in the 'patient' module of the application, including defects, enhancements, issues and documentation changes with a flexible workflow process using QualityCenter
• Verified the software and applications according to the requirement specifications SRS and generated detailed test coverage reports and graphs twice a week
• Worked closely on documentation in regards to GMP and traced it through various procedures to ensure quality and avoid contamination.
• Used documented for content management.
• Involved in validation of HIPAA 834, 270/271 EDI transaction codes.
• Developed the Project using the Iterative RUP model. The Project was streamlined through all phases of the Rational Unified Processes RUP model starting from Inception through Transition. Used a Functional Decomposition strategy to divide system into sub-systems.
• Designed message formats, queues, legacy systems interfaces, and worked with the business users through interviews and Joint Application Development JAD sessions. Created front-end prototypes as deliverables and projected the end-delivery modules.
• Conducted data Driven tests in Win Runner by parameterization, worked with the data table, modified the script for data-driving, and wrote SQL statement in Script to retrieve data from database.
• Prepared requirement specification, functionality trace matrix, quality assurance plan and designed test cases. Communicated with business, technology leadership for overall project/program office milestones.
• Evaluated application testing results and recorded the discrepancies using QualityCenter to track, analyze and report on them.
• Used QualityCenter as a repository for Test Cases and Test Scripts. Responsible for monitoring the defect tracking process and generating customized reports using QualityCenter. Interfaced with developers to resolve the bugs following the bug life cycle policy.

Environment: QualityCenter, Rational RUP, UML, Quick Test Pro, SQL Server, MS-Project, MS Visio, HIPAA compliances.

Confidential

Business Analyst

Confidential PPO, and POS plans, as well as consumer-directed options. They also offer individual plans, as well as coverage for Medicare beneficiaries.Project was to develop new software that will determine the eligibility of a Medicare recipient, processing Medicaid request forms, Medicaid claims, check if funds available and also help staff into looking each costumers data to check eligibility of costumer for the Medicaid and help them best as possible.

Responsibilities:

• Gathered Business Requirements. Interacted with the Users, Designers and Developers, Project Manager to get a better understanding of the Business Processes.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for TennCare processing of Medicaid Claims.
• Liaison between the Business needs business users and sponsor and the Technical solutions development and testing staff , ensuring technical solutions satisfied business requirements.
• Performed Web Page Mock-Ups using MS Visio and thus defining the Business Process Model and Data Process Model.
• Experienced in RUP software development cycle methodology with four consecutive phases - Inception, Elaboration, Construction and Transition.
• Developed gap analysis document, logical and physical design and remediation plan for State.
• Responsible for mapping documents, creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Worked with business owners, content staff, IT and other stakeholders in creating a content management solution for managing the information in the supplier portal using WebSphere Application Server.
• Built and customized SoDA for Word templates and extract information from information sources such as RequisitePro and Rose, and created a highly automated system for handling approvals, exceptions and priorities.
• Used the Rational Unified Process RUP to build the different phases of Software development life cycle
• Created Project management plans for managing on time delivery using MS Project along with writing test cases, unit and systems integration test plans in WinRunner and used LoadRunner to check if application works fine with load.
• Creating and analyzing numerous clients' reports for various financial requirements.
• Documenting workflow and results of analysis for the aging accounts.

Environment: OO Modeling, Web Sphere, Rational RequisitePro, Rational Rose, Rational SoDA, RUP, UML, Load Runner, MS-Project, MS Visio, Java, MS Office, Windows XP