SUMMARY

• An accomplished IT Professional with 6 years of experience as a Business Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling.
• Experienced working on 5010 HIPAA implementation guides relate to Claims and enrollments.
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum and Software Testing Life Cycle (STLC).
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document (BRD) and Functional Requirement Specifications (FRS) document.
• Facilitated one on one interviews and Joint Application development (JAD) sessions
• Experienced in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Involved in maintaining performing GAPanalysis, Requirement Analysis, and Document Analysis.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claimsadjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277).
• Proven ability to support multiple complex projects under tight deadlines, often with competing priorities.

TECHNICAL SKILLS

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management Tools: Jira, Rallydev, MS Word, MS Visio, HP ALM

Operating Systems: Windows 2000/10/XP, DOS

Languages/Standards: SQL, XML, JSON, HIPPA 5010, ICD10

Methodologies: Agile, Waterfall

Tools: QNXT, BizTalk, Edifecs, SSMS

PROFESSIONAL EXPERIENCE

Confidential, NJ

Business System Analyst

Responsibilities:

• Work with IT department to automate submission of transactions. The process includes importing claims into the revenue reconciliation manager that had been adjudicated and setting them to an ’02’ (Finalized) status so the claims can be sent to the reporting authority.
• Execution of weekly, bi - weekly and monthly reports and the creation of adhoc reports.
• Help QA to test requirements to ensure proper development and deployment.
• Logging all CSV files, outbound 837 files and 999/277CA files.
• Checking Recon report daily to ensure that all claims were successfully made into outbound encounters for submission
• Create queries and reports to assist operations with the analysis of data relating to claims, members and providers.
• Work with the implementation manager on various management activities like keeping track of project statuses and deadlines/milestones
• Co-conduct meetings with development team to discuss any requirement changes.

Environment: Windows 2000 /XP, Microsoft Office SharePoint, Rational Requisite Pro, MS Office, MS Project, SQL Server, MS Project, MS Visio, MS Access, EDI, HL7, UML

Confidential I Princeton, NJ

Business System Analyst

Responsibilities:

• Submit and gain approval of EDI encounter transactions.
• Worked on Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
• Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
• The process included importing claims intoQNXTthat had been adjudicated and setting them in a "PAY" status so that a payment cycle could be run to create cheques.
• Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure required interactions are met during the SDLC process.
• Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors with the process of EDI inbound and outbound files.
• Business Process Analysis/End User Education/Business Requirements Documentation.
• Validated System configuration, including enrollment, provider and benefits modules.
• Creation of queries and reports to assist Health Plan Operations with the analysis of data relating to claims, members and providers.
• Execution of daily, weekly and monthly reports and processes and the creation of ad-hoc reports.
• Applying of CCHP departmental processes, procedures and data.

Environment: QNXT, MS Visio, MS Project, SQL, Oracle, MS Access, MS Excel and MS Word.