SUMMARY

• Senior Business Analyst with 6+years of experience in business process analysis/modeling, business requirements gathering, database design and development of Web Based, and Client/Server applications.
• Experience as Business Intelligence/Systems/Data/Business Analyst with expertise in Insurance, Healthcare processes, Business Process Engineering, Systems/ Solutions Engineering, Strategic Planning, and Systems Analysis.
• Assisted the PM participated in Product demonstration and highly involved in RFP Selections and closely worked with SMEs / Users to prioritize the Change / Work requests and adjust the budget accordingly.
• Proficient in business process modeling, documentation, and testing using Rational Suite (Rational Rose, Requisite Pro, Clear Quest) as well as MS Visio and MS Project in combination with UML 2.0 diagramming techniques.
• Experience configuring QNXT applications for case management, flexi conversion, provider, member, member eligibility, and prior authorization.
• Proficient in all aspects of QNXT configuration including eligibility and enrolment, provider reimbursement and network management, referral and authorizations, claims processing, and premium billing and accounting.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Assigned tasks among development team, monitored and tracked progress of project following Agile methodology
• Requisite Pro, Rational Rose, Agile, HL7 Interfaces, PL/SQL, HTML, MS Office, MS Visio, EDI, UML.
• Exposed to Agile methodology
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Communicate with vendor to regarding new updates on Facets and solution to their existing system
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Tested the changes for the front - end screens in FACETS related to following modules, test the FACETS batches (, Billing, Provider, etc).
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Strong knowledge of Facets and actively involved in end-to-end implementation of Facets Billing, Enrolment, Claim Processing and Subscriber/Member module.
• Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS - enrolment and benefits.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider
• In-depth knowledge of creating use case, activity, logical, component and deployment views with rational tools to extract business process flows and workflows thereby helping development and quality assurance teams in understanding the requirements.
• Results-oriented Joint Application Development (JAD) Facilitator and meetings coordinator with excellent interpersonal skills.
• Analytical, methodical, and resourceful approach to problem solving, identifying and documenting root causes and corrective actions
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, Primavera, MS Access, MS Visio, technical assessment tools, Data Warehousing concepts and web design and development.
• Experience in Change Management Process (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Strong oral and exceptional written business communication skills
• Hard working, positive thinking, self-starter with a strong goal orientation
• Excellent meetings facilitator with excellent inter-personal and conflict resolving skills.
• Proven success as a business analyst through the years, providing a well-balanced understanding of business relationships, business requirements, and technical solutions.

TECHNICAL SKILLS

Programming Languages: C,C++,C#,VC++,VB,VB.NET,C#.NET, ASP.NET, Java, SQL, PLSQ

Development Methodologies: RUP, AGILE, Waterfall, ESDM, STV

Databases: MS-Access, My SQL, SQL Server, Oracle, Teradata, DB2, Sybase

Application Servers: IBM WebSphere, ATG Dynamo, BEA Web Logic.

Internet: HTML, XML, VBScript, ASP, JavaScript, JSP, J2EE.

Automation Tools: MS Visio, Rational Rose, Rational Clear Case, Rational Requisite Pro, Documentum

Bug Tracking Tools: Mercury Test Director, Rational Clear Quest

Utility Tools: MS Office Suite, MS Project, TOAD, Adobe Photoshop

Reporting Tools: Crystal Reports, SQL Server Reports (SSRS)

Data warehousing Tools: Informatica, Business Objects, Cognos, Erwin

Testing Tools: Quick Test Pro (QTP), Test Director, Win Runner, Load Runner, Niku Project Work Bench

PROFESSIONAL EXPERIENCE

Confidential, Marlton NJ

Business Analyst

Responsibilities:

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Responsible for integrating with Facets .Designing test scripts for testing of Claims in Development, Integration and production environment.
• Conducted user interviews and documented business and functional requirements.
• Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Upgraded HMO Medicare EDI and reporting.
• Completed the documentation of Claims Scenario’s for the source system
• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Prepared for GAP Analysis; identified and documented improving areas to meet capital requirement regulations.
• A highly motivated, results-focused Senior Medicare Analyst with over ten years of experience in the Health Plan industry. Possess strong leadership and successful team building capabilities and excellent technical, communication, presentation, and customer service skills.
• Served as interdepartmental liaison for all MA/MAPD/PDP/Cost Medicare Enrollment/Eligibility questions.
• Project managed all CMS requirements in Enrollment and Billing including Policies and Procedures and Medicare Enrollment Letters.
• Created and maintained requirement documents for Facets for the different modules like Billing, Member enrolment and Claim adjudication
• Documented Medicare claims processing.
• Possess expert knowledge inTrizetto Facets™,Online, data modelandBatches
• Expert knowledge ofHIPAAX12 EDI transactions such as 837 and 835.
• Designed High level design, for New process, integrating with legacy and Facets
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Organizing JAD sessions, personal interviews and surveys in the process of collecting requirements including that of G.M.’s and other higher management
• Exposed to Agile methodology.
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Created use case scenarios and documented work flow and business process using Rational Rose
• Involved in project management using MS Project
• Collaborated with External Auditors and documented SOX compliance requirements
• Documented requirements, associated change requests with requirements and connected requirements with Use cases.
• Wrote test cases and test scripts for the User Acceptance Testing
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Maintained benchmark controls to policies, company standards and contracts, performed vendor sourcing, pricing and contract negotiation, performed procurement, ensured compliance with service/joint interest contracts.
• Used Rational Clear case for version control
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.
• Queried database using SQL for backend testing
• Used Rational clear quest for defect management

Environment: Windows XP Professional, Oracle9i, MS Access 2000, MS Excel, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.

Confidential, Franklin Lakes, NJ

Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Involved in all phases of software development life cycle(SDLC) in AGILE framework.
• Designed and analyzed Business Process Model,Use case Model, and Test procedures based on AGILE methodology.
• Functional Knowledge of Medicaid Management Information System MMIS .
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Coming up with Design plan and Preparing the ETL Design document
• Automating the ETL applications using Tidal tool
• Co-ordinating/Managing ETL Offshore team
• ETL Architect(Informatica and PL/SQL) /SME
• Converting the Business rules into Technical Specifications for ETL process
• Scheduled the ETL jobs daily. Weekly and monthly based on the business requirement
• Extensively worked in the performance tuning of programs, ETL procedures and processes.
• Expertise in validation of ETL process by writing SQL queries using complex joins and Analytic functions against Oracle & SQL Server databases. years of strong data warehousing experience using Informatica PowerMart 6.1/5.1/4.7, PowerCenter 8.x/7.x/6.x/5.1/1.7 as ETL tool
• Expertise in the EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Currently leading, coordinating EMR/EHR (iHelix Suite) implementation to achieve meaningful use stage 1.
• Performing business analysis, software validation and testing for client/server, multi-tier and web-based applications for EMR and commercial business for managed healthcare plans and Industries
• Testing the accuracy of iHelix inpatient EMR for Stage 1 meaningful use clinical quality measure calculation by using Cypress tool.
• Capture Feature/Function information at varying levels of granularity and document them in a requirements management tool (e.g. Microsoft TFS, JIRA, etc.)
• Familiarity with a requirements management tool like MS Team Foundation Server, JIRA or the like
• Helped lead the transition of Requirements Management in theBusinessAnalystTeam to the agile methodology by creating and managing user stories and Requirements Traceability Matrices in the JIRA toolset.
• Report on project status to appropriate project management chain using Jira
• Functional Knowledge of Medicaid Management Information System MMIS .
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Created test data from claim processing for different FACETS Modules like hospital, medical and dental claims.
• Experience on working with the Trizetto FACETS 4.31, 4.51, 4.71Data models.
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Checked Business Readiness and determined activities of flow.
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Managed various tests, stored test information, reviewed and analyzed test results.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Helped in writing manuals and helped business with the on a one to one sessions.
• Act as Primary Point of Contact (POC) for all major (critical and high priority) tickets providing leadership and facilitation of "CIRT” (critical incident response team) exercises.
• Conducted impact analysis of issues logged prioritize and ensure that production support is provided as per the committed SLAs.
• Performed root-cause analysis of any issues that arise on pre & post-implementation and work on solutions related to issue fixing.
• Supported the creation of the Go Live plan and manage the assigned activities in the plan
• Managed resource availability and assign tickets to techs
• Ensured all issue owners follow ticket guidelines (Playbook/requesting support)
• Worked with Facilitators /SME/Tech Lead/BATS/etc. for ticket status reporting and resolving outside dependencies. Set up a meetings as necessary
• Published work priorities of current shift and create initial draft for next shift
• Managed and track the progress of the issues and maintain Sharepoint tracking systems to ensure proper communication and documentation for executive management.
• Championed project management of client issues,including coordination between project and technical resources to support issue resolution,and coordination of operational readiness requirements.
• Modified time lines and work schedules according to project changes.
• Excellent interpersonal and communication skills,complementing proven creative problem solving capabilities.
• Excel at organizing,coordinating,and managining projects.
• Conducted User Acceptance Testing (UAT) prior to and after implementation phase.
• Created SQL queries involving Joins, Functions and Stored Procedures.
• Worked on the modification of existing SQL queries in the reports, creating new queries, modification of existing actuate basic code, adding new columns in between the existing columns in the report layout, adding new conditions and addition of a completely new section in the report structure.
• Worked with issues coming from, Cross, Operational tables in the Oracle Database and updating the tables per the requirements using Oracle, SQL.
• Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions.
• Created use cases specifications, use case diagrams, swim lane diagrams, component diagram and context diagrams to define the workflow and segregate high-level and low-level requirements using MS Visio.
• Conducted and Participated JAD sessions to gain consensus on various issues related to the project. Acted as a facilitator on different occasions.
• Held regular meetings with the Business users and SME’S to priorities the business Requirements.
• Conducted walkthroughs and code reviews with developers, project managers and stakeholders and users to comprehend business workflow of applications.

Environment: Teradata,DB2, RUP, UML,VB .Net, Rational Requisite Pro, Rational Clear Case, XML, MS Visio, MS project, MS Word, MS Excel,, Win runner, Load Runner, SCCD (IBM Smart Cloud Control Desk), Quality center.

Confidential, Franklin Lakes, NJ

Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Involved in all phases of software development life cycle(SDLC) in AGILE framework.
• Designed and analyzed Business Process Model,Use case Model, and Test procedures based on AGILE methodology.
• Functional Knowledge of Medicaid Management Information System MMIS .
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Coming up with Design plan and Preparing the ETL Design document
• Automating the ETL applications using Tidal tool
• Co-ordinating/Managing ETL Offshore team
• ETL Architect(Informatica and PL/SQL) /SME
• Converting the Business rules into Technical Specifications for ETL process
• Scheduled the ETL jobs daily. Weekly and monthly based on the business requirement
• Extensively worked in the performance tuning of programs, ETL procedures and processes.
• Expertise in validation of ETL process by writing SQL queries using complex joins and Analytic functions against Oracle & SQL Server databases. years of strong data warehousing experience using Informatica PowerMart 6.1/5.1/4.7, PowerCenter 8.x/7.x/6.x/5.1/1.7 as ETL tool
• Expertise in the EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Currently leading, coordinating EMR/EHR (iHelix Suite) implementation to achieve meaningful use stage 1.
• Performing business analysis, software validation and testing for client/server, multi-tier and web-based applications for EMR and commercial business for managed healthcare plans and Industries
• Testing the accuracy of iHelix inpatient EMR for Stage 1 meaningful use clinical quality measure calculation by using Cypress tool.
• Capture Feature/Function information at varying levels of granularity and document them in a requirements management tool (e.g. Microsoft TFS, JIRA, etc.)
• Familiarity with a requirements management tool like MS Team Foundation Server, JIRA or the like
• Helped lead the transition of Requirements Management in theBusinessAnalystTeam to the agile methodology by creating and managing user stories and Requirements Traceability Matrices in the JIRA toolset.
• Report on project status to appropriate project management chain using Jira
• Functional Knowledge of Medicaid Management Information System MMIS .
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Created test data from claim processing for different FACETS Modules like hospital, medical and dental claims.
• Experience on working with the Trizetto FACETS 4.31, 4.51, 4.71Data models.
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Checked Business Readiness and determined activities of flow.
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Managed various tests, stored test information, reviewed and analyzed test results.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Helped in writing manuals and helped business with the on a one to one sessions.
• Act as Primary Point of Contact (POC) for all major (critical and high priority) tickets providing leadership and facilitation of "CIRT” (critical incident response team) exercises.
• Conducted impact analysis of issues logged prioritize and ensure that production support is provided as per the committed SLAs.
• Performed root-cause analysis of any issues that arise on pre & post-implementation and work on solutions related to issue fixing.
• Supported the creation of the Go Live plan and manage the assigned activities in the plan
• Managed resource availability and assign tickets to techs
• Ensured all issue owners follow ticket guidelines (Playbook/requesting support)
• Worked with Facilitators /SME/Tech Lead/BATS/etc. for ticket status reporting and resolving outside dependencies. Set up a meetings as necessary
• Published work priorities of current shift and create initial draft for next shift
• Managed and track the progress of the issues and maintain Sharepoint tracking systems to ensure proper communication and documentation for executive management.
• Championed project management of client issues,including coordination between project and technical resources to support issue resolution,and coordination of operational readiness requirements.
• Modified time lines and work schedules according to project changes.
• Excellent interpersonal and communication skills,complementing proven creative problem solving capabilities.
• Excel at organizing,coordinating,and managining projects.
• Conducted User Acceptance Testing (UAT) prior to and after implementation phase.
• Created SQL queries involving Joins, Functions and Stored Procedures.
• Worked on the modification of existing SQL queries in the reports, creating new queries, modification of existing actuate basic code, adding new columns in between the existing columns in the report layout, adding new conditions and addition of a completely new section in the report structure.
• Worked with issues coming from, Cross, Operational tables in the Oracle Database and updating the tables per the requirements using Oracle, SQL.
• Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions.
• Created use cases specifications, use case diagrams, swim lane diagrams, component diagram and context diagrams to define the workflow and segregate high-level and low-level requirements using MS Visio.
• Conducted and Participated JAD sessions to gain consensus on various issues related to the project. Acted as a facilitator on different occasions.
• Held regular meetings with the Business users and SME’S to priorities the business Requirements.
• Conducted walkthroughs and code reviews with developers, project managers and stakeholders and users to comprehend business workflow of applications.

Environment: Teradata,DB2, RUP, UML,VB .Net, Rational Requisite Pro, Rational Clear Case, XML, MS Visio, MS project, MS Word, MS Excel,, Win runner, Load Runner, SCCD (IBM Smart Cloud Control Desk), Quality center.

Confidential

EDI Analyst

Responsibilities:

• Assist with creation and maintenance all necessary documentation and materials for Epic Ambulatory application
• Performed analysis, design, development and maintenance of the Epic Ambulatory applications and other clinical information systems
• Expert knowledge in developing and configuringFacets Extensions(Embedded,XCOM, XSQL)using C#, VB .NET, SQL, and VB
• Expert knowledge in design and implementation of custom Interfaces, Extensions, Data Extracts onFacetsplatform.
• Extensive experience in Facets version upgrades projects.
• Strong knowledge of Claims In and processing flow within Facets platform.
• Possess strong knowledge inITS Home & Hostimplementation on Facets platform
• Performed impact analysis of Facets version upgrade changes.
• Provided Facets system solution and technical design, for business problems.
• Analyzed the Facets billing configuration and designed the Refund letters process for Consumer billing project.
• Developed and implemented policies and procedures which includes process flows, guide sheet for all important responsibilities as part of development of Medicare Operations Manual.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. 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.
• Interacted with the DST (off shore) teams for QA support and purposes. Responsible for running test region EDI loads on AS400 Series. Updated records in AS400 before processing for testing purposes.
• 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.
• Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and 271.
• Experience with EPIC user and provider record provisioning, including the development of role-based access, security classes, and user profiles
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Experience in Epic Resolute product implementation and deployment
• Hands on experience with Epic Hospital Billing and Ambulatory
• Full knowledge of application interoperability configurations and managed the implementation tasks of HIE clinical applications.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. 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 Enrolment hence analysing and documenting related business processes
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Experience with Epic Healthcare Information Systems
• Conducted user interviews, gathered requirements, and analysed the requirements.
• Trained thousands of medical providers w/ ten member team on HIE software and insurance proprietary software Managed 1500 medical provider accounts including group practices, large health systems and hospitals
• Worked with the business team to collect the business requirements, security and service level requirements and documented them.
• Analysed set behaviour and contribution to business performance, critical business metrics & tracking underlying business trends using Business Objects.
• Working with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects
• Participated in the logical and physical design sessions and developed design documents.
• Designed new process flows for the existing system as well as for the enhanced system.
• Conducted and lead status report meetings with the business and the IT team on a weekly basis.
• Manage Scope and change throughout the life cycle of the product.
• Performed collection, coding, and assessment and reporting of adverse event data using ARISg.
• Worked in the ARISg Implementation of the EHR-Pharmacy Module.
• Supported integrating EDI batch processing and real-time EDI
• Recommend tactic to implement HIPAA 4010 (EDI X12 837,834,278,270) in the new System
• Worked on Electronic health record system as a CRM web based application.
• Working Experience in Electronic Submissions in standard format E2B.
• Knowledge of regulatory issues including State, Federal, AABB, CAP, CLIA, and JCAHO

Environment: Windows 7, MS Project, Microsoft Visio, SQL, Data Warehouse, BI, BO, EPIC, HL7 and Business Objects