SUMMARY:

• Healthcare Business System Analyst with 5+ years of experience in Health Care insurance, Medicare and Medicaid.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Test Plan, maintaining the Traceability Matrix
• Good experience in the EDI transactions and knowledge on EDI transaction process flows.
• Strong experience and understanding of health care industry, claims management process, Knowledge of Medicaid and Medicare Services.
• Good documenting and excellent communication skills.
• Experience with QNXT, Edifecs, Facets db, Medicare and Medicaid and HIPAA compliance standards.
• Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicaid, Medicare, Managed Care, Utilization Management, MMIS and implementation of HIPAA key EDI (ANSI X12) transactions.
• Expertise in SDLC methodologies which includes significant experience in Waterfall and Agile methodology.
• Highly proficient in working with users and stakeholders to elicit, analyze, communicate and gather requirements using techniques such as Brainstorming sessions, Workshops, Observation and Existing systems documentation/procedures, JAD, User Interviews and to identify Functional, Non - Functional, Business and System Requirements and then subsequently document them.
• Evaluate solution to ensure it is adding value or satisfying stakeholder expectations.
• Sound knowledge of HIX, PPACA, NCPDP and Healthcare regulations.
• Create Business Requirement Document (BRD), Functional Requirement Document (FRD), Technical specification Document (TSD), Requirement Traceability Matrix (RTM), Scope Statement and other project related documents.
• Implemented knowledge of Distributed Web Services/ Enterprise / Web / Client- Server systems using JSON.
• Hands on experience with QNXT, Edifecs, claim processing systems, Service.
• Extensive experience in writing SQL queries for data gathering and generating reports.
• Conduct walk through of deliverable, component validation, solution evaluate & solution approval and critical requirement prioritization for upcoming releases.
• Extensive knowledge of reporting tools such as SQL and ACCESS for underlying database tables and resolve data issues.
• Gathered Functional andDataRequirements, analyzed workflows and created Use Cases, Requirement Specifications, Report Specifications,DataRequirements,DataMappings andDataFlow Diagrams.
• Advance proficiency in Microsoft, particularly Word, Excel, PowerPoint, Visio and Project.
• Validated 837 (Healthcare Claims), 835 (Healthcare Claims payment / Remittance), 276/277 (Claim Status inquiry and response).
• Worked on healthcare standards such as HIPAA 5010, ICD-10, FHIR format
• Good knowledge of EHR (Electronic Health Records) in compliance withMeaningfuluseprogram and HIX (Health Insurance Exchange) etc.
• Experience in SQL to perform data analysis, data mapping, data verification & data validation
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio a.
• Knowledge and expertise in working with Claims, Provider, Enrollment, Finance, Benefits, and Vendor Management Business Areas.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.

TECHNICAL SKILLS:

Project Methodologies: SDLC, UML, Agile, SCRUM

Business Modeling Tools: Microsoft VisioPlatformsWindows

Testing tools: HP ALM

Change Management Tools: Rally, Jira

Office Tools: MS Project, MS Office, MS Visio

Database: MS SQL Server, MS Access, and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Hartford CT

Business Analyst

Responsibilities:

• Worked with QNXT Claim processing system
• Wrote requirement for developer, testers including dependencies, assumptions
• Followed agile methodology to gather the Business Requirements and designed Functional specifications.
• Worked with Enterprise team to enhance EOB mapping document including CVS & Molina Pharmacy claims
• As a source BA on Medicaid backend, answered queries for provider team, enrollment team
• Worked on Medicaid Web Portal to verify claim records
• Worked with batch processing files, distribution list to send out email notification
• Data partitioning of data coming from health plan
• Set up new account/role for Medicaid health plan (Aetna Better Health of IL) Case worker
• Added feedback in various meeting with technical leads, architect, SME leading to solutions
• Facilitated daily scrum meetings in absence of Scrum Master
• Worked with Scrum master to add, update user stories in Backlog, Scrum board for future sprints
• Medicaid system Validate 834 EDI files data, request for batch job to load the files and validate in QNXT Front End.
• Tested the changes for the front - end screens in Medicaid Web Portal related to its modules (, Billing, Provider, etc.).
• Organized and facilitatedAgileand Scrum meetings, which included Sprint Planning, Daily Scrums or Stand ups, Sprint Check-In, Sprint Review & Retrospective.
• Analyzed systems specifications, requirements and developed use cases accordingly.
• Identified the crosswalk table schema to persist the mapping of new system to existing system codes.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection.
• Facilitated the Meetings with Business owners, SMEs and Business user to gather the requirements. This includes face to face as well as WebEx interaction.
• Create internal reports using Dashboard and basic SQL queries in the tool to track activities of the teams.
• Created data mapping documents mapping Logical Data Elements to Physical Data Elements and Source Data Elements to Destination Data Elements.
• Documented variousUse Case scenarios,Process Flowsand other diagrammatic representations inMS Visio.
• Responsible for the full HIPAA compliance life cycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Analyzed and developed the Use Case Model, Analysis model, Behavior diagrams based on UML Methodology & Business process flow diagrams using Visio.
• Involved in taking further steps to streamline the provider enrollment process with a single application for Medicaid and the variouscaremanagement organizations.
• Extensively used Claims processing, Provider, Subscriber/Member, Utilization Management applications in QNXT.
• Involved in identifying use cases, and writing use case narratives and created use case diagrams and activity diagrams using MS Visio

Confidential, VA Beach VA

Business Analyst

Responsibilities:

• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non - functional requirements.
• Wrote User Stories -- Elaborated User Stories and Acceptance Criteria; Reviewed user stories with internal team
• Wrote high level and detail level requirements, review requirements with business ops
• Wrote acceptance criteria, testing scenarios for each requirement
• UAT testing, assigned defects to testing team, created Jira tickets
• Validated claims against requirements, did analysis of claims that had been rejected, Root Cause Analysis of Encounter by verifying claim information in QNXT db and Edinet (Vendor db)
• Created, updated requirement in Jira, and assigned tickets to developers, testers
• Tested user stories and sign off on the business functionality completeness.
• Used sql queries to look up data in db, worked on stored procedures to verify query logic
• Worked with Edifecs to check individual Encounters to check for missing or invalid data
• Batched claims to State in Edifecs, and reloaded Remits in Edifecs for further analysis on claims
• Verified and Root Analysis Cause of errors in remits 999 and 277
• Scheduled the meetings with domain leads to determine the mapping parameters for each field.
• Manually over rode claims in Edifecs to be in compliance
• Created Jira tickets to implement fix for the rejected claims in Edifecs
• Was involved in analysis on 837P and 837I Electronic Data Interchange EDI file to analyze claim lines, amount paid and other secured information on professional claims and Institutional claims.
• Supported in collecting HIPAA related EDI transactional data from data warehouse.
• Wrote User stories which included the business logic, expected behavior and user acceptance criteria.
• Worked on EDI transactions: 837 (P, I, D) to identify key data set elements for designated record set. Interacted with Claims, Payments, and Enrolment hence analyzing and documenting related business processes.
• Involved in impact analysis of HIPAA 5010: 835 and 837 transaction sets on different systems.
• Managing backlog for the Scrum team and acting as a feature product owner from a business/stakeholder standpoint.
• Participated in requirement refinement meeting
• Worked with Market leads on CMS on refining requirements for Medicare A/B
• Performed the Back - End integration testing to ensure data consistency on front-end by writing and executing SQL statements on the Database.
• Created pivot table in excel to determine errors and create a list for the errors on CSV file
• Validated data on CSV file, manually added segments to CSV file
• Performed GAP analysis on management and claims processing to evaluate the adaptability of the new application with existing processes.
• Organized meetings and attended JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met.
• Highly involved in Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the change in the proposed system.
• Conducted UAT and documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criterion for the requirements has been included in the UAT task plan.
• Analysis of inbound and outbound interfaces and extensions to in house Claims Processing system.
• Conducted walk through sessions for Business Requirement Document (BRD) and Use Cases to discuss certain issues with stake holders, Architectures and Design & development teams and also did GAP Analysis.

Confidential, Hartford CT

Jr Business Analyst

Responsibilities:

• Created In/Out scope Macro document which consisted of dependencies, assumptions, risk.
• Reviewed, analyzed and created detailed documentation of business systems and user needs, including workflow, program functions
• Conducted User Acceptance Testing (UAT) and documented Test Cases.
• Gather business requirements, analyzed workflows and created use cases
• Reviewed and analyzed the Use cases and come up with Test plan templates
• Wrote various SQL queries for the bac kend using various joins to interact with database.
• Responsible for conversion of data in Data Mapping and writing transformation rules.
• Worked with look up tables, structure tables and identifying the needs according to business requirement
• Worked with ALM tool to log in defect and followed with testing team to finalized solution
• Wrote User stories which included the business logic, expected behavior and user acceptance criteria.
• Thoroughly communicated day-to-day status of current projects to stakeholders.
• Involved in analysis of requirements for LTC, Waiver, Death, Disability Claims.
• Worked with Slowly Changing Dimension data and historical data

Environment: Windows, Agile/Scrum, MS Access, JIRA, SQL, MS Office suite (Word, Excel, PowerPoint, Visio), XML, UAT.

Confidential, Greensboro NC

Jr Database Administrator

Responsibilities:

• Performing daily maintenance including monitoring backups, managing disk space, and maintaining database objects
• Participating in on-call rotation and working occasionally after hours or on weekends
• Able to analyze issues with limited assistance. Gaining experience while assisting team members in analysis, problem solving and operational tasks
• Creation/cloning of database instances for development and testing purposes
• Design, develop, and maintain optimized databases for testing, production, and
• Provide ongoing consultation and documentation on the design, accessibility, and maintenance of database systems
• Maintaining client documentation including database topology, connection procedures, and special instructions
• Providing database security administration such as User ID’s, Passwords, roles, etc
• Created Users and assign permissions based on the level of database access the user would need.
• Created, backed up, and restored databases.
• Backed up and recovery of the database.
• Responsible for finding dollar amount discrepancy on reports from 175 Confidential stores
• Trouble shoot sql jobs, SSIS projects and worked with stored procedures to able to continue smooth flow of data
• Wrote adhoc queries, worked with Test, Dev, Production environment
• Supported QA, BA work and BI team
• Monitor and manage alert logs and trace files
• Configure and monitor Database backups including both hot and cold backups
• Interface with Tech Support for information gathering, trouble-shooting, and general technical support
• Ensure system is running smoothly and troubleshoot and correct issues as they arise