SUMMARY

• Healthcare Technical Business Analyst with 7+ years of experience in teh Healthcare Industry on various areas like Claims Processing, Configuration, Billing, Insurance and Reimbursement, Medicaid, and Medicare Services with a solid understanding of Data Analysis Data application, SDLC documentations, Business Process Flows, and Business Analysis. Detail - oriented and good documentation and process management skills
• Performed Gap Analysis of client requirements, generated workflow process, flow charts and relevant artefacts using UML diagrams.
• Experienced in data analysis with solid understanding of Business Requirements Gathering, Data warehousing, Data Mapping and Data Modelling.
• Knowledge of various areas like CPT, HCPCS, General equivalence Mappings, Healthcare claims processing, Medical policies, Benefits, Network Provider Management, Enrolment/Membership and Utilization Management etc.
• Good noledge of teh Facets Enrolment, Billing and Clams modules for Healthcare Management.
• Experience gathering and documentation of requirements, acceptance criteria and other artifacts using teh SDLC application.
• Experienced in software development life cycle such as Waterfall, Agile-SCRUM methodologies, BusinessAnalysis and Modelling.Participate in teh organization IT direction and roadmap.
• Solid Experience in developing Scope/Vision Documentation and Project Plan. Strong noledge of creating conceptual data models, ER diagrams, data mapping, data profiling, data verification, data integrity, ETL process, data normalization, data dictionary, SQL queries for data analysis and data validation.
• Expertise in Claims Life Cycle, Healthcare Claims processing systems such as Health Edge, Health Rules, Health Trio and Health Suite.
• Created context and workflow models, information and business rule models, Use Case and Object Models during teh analysis using rational tools.
• Strong noledge of working on JIRA and Utilized it to develop and track agile epics, stories, and tasks.
• Excellent working noledge of SQL Server Reporting Services (SSRS), SQL Server Integration Services (SSIS), SQL Server Analysis Services (SSAS).

TECHNICAL SKILLS:

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

Requirements Management: Rational Requisite Pro

Business Modeling: Rational Rose, MS Visio

Defect Tracking Tools: Rational ClearQuest

Languages/Standards: SQL, XML, HTTP, Java, HIPPA 4010/5010, ICD9/10, ANSIX12

Methodologies: Rational Unified Process (RUP), Agile, Waterfall

PROFESSIONAL EXPERIENCE

Confidential

Technical Business Analyst

Responsibilities:

• Advised members, providers, brokers and group administrators of member eligibility, benefits, exclusions, and limitations on teh Senior Advantage Medicare Replacement Plan.
• Configure provider contracts for Independence Health group as business is moved to teh Health Edge software platform.
• Worked as a Technical analyst/Business consultant with Health Edge Payor system organization specifically for teh clients and Riverside Benefits and claims administrative organization
• Liaised with end users on system design challenges and preferences in relationship to clinical processes and procedures; presented these findings to application. Development team, making recommendations according tobilling workflowand end user needs.
• Created reconciliation reports and teh rules to match/combine/delete or provide exceptions to teh discrepancies.
• Facilitated interview, one on one and brainstorming sessions with SME's User's in understanding teh requirements pertaining to billing Origination to billing Processing
• Created desktop level instructions, summary-level of processes, and development creation of functional attributes of a successful reconciliation statement per requested requirements
• Involved in Joint Application Development sessions with SMEs and development teams and documented functional business requirements as product backlogs using JIRA
• Assist in teh development of a Business Plan for teh future of Health Edge’s web presence applications that wrapped around teh organizations core enterprise-wide claims processing and billing system.
• Worked in Upgrading Applications software and DevOps tools to teh latest version in cloud environment.
• Involved in analysing and processing of teh benefit plan administration business health rules to enforce teh state policies to diagnosis and procedure codes
• Gathered detailed business and technical requirements and participated in teh definitions of health rules and data standards.
• Proficient in all aspects of Facets configuration including eligibility and enrolment, provider reimbursement and network management, referral, and authorizations, claims processing, and premium billing and accounting.
• Responsible for securing requirements that can be understood by both Business and IT and using agile / Rally, Azure DevOps.
• From a Customer Experience perspective, support teh Confidential core platform transition to teh Health Edge software system (Health Rules) which serves to provide enrolment, benefits, billing, claims adjudication, provider data and pricing functionality.
• Demonstrated experience and understanding of teh methodology testing in a DevOps environment, which include experience in using Jenkins for auto deployment of a build.
• Tested teh changes for teh front-end screens in FACETS related to following modules, test teh FACETS batches membership, Billing, Provider
• Experience working in a DevOps environment and delivering enhancements to improve teh application environment
• Involved in analysing and processing of table driven benefit plan structure, recipient plan, and provider contract and reimbursement agreement business for health rules to process claims to pay, deny or suspend.
• Supported teh application of teh Scrum and SAFE Agile Methodologies in developing and managing teh application development process.
• Analyse business requirements and document them appropriately in teh form of user stories in Jira and/or Azure DevOps.
• Use Case creation for training instance of Health Rules Payor by Health Edge. Develop and maintain Automated Test Framework using Selenium, TestNG, and Cucumber with WebDriver to support teh Health Rules Payor™ platform.
• Involved in end-to-end testing of Health Rules Manager Application for Billing, Enrolment Claim, Processing and Subscriber/Member module.
• As a Business Analyst I was responsible for testing Health Rules Application health plans for subscribers
• Executed SQL queries to test teh databasefor records that detect and submit functional acnoledgement and remittance advice teh claims application.
• Provide technical support on teh various vendors using JIRA and Confluence Collaboration tools as well as grant users access to Ticketing System.
• Served as a Relationship between internal and external business community Claims, Billing, Membership, Customer service, Healthcare Management, and teh project team.
• Worked extensively with developing business rules engine enabling teh business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
• Worked as a part of scrum team, in an agile methodology with sprint cycles, daily stand ups and story implementation. Large cross functional project and support teams.
• Conducting JAD sessions with different Business Users to develop new policies and procedures for teh Service Catalogue, Charge Capture and Service Worklist /Charge Router, Hospital billing, coding, special coding requirements and Claim processing.
• Create and executerevenue cyclemedication Epic billing data and reports from decision support and billing systems. Analysed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed.
• Provide technical support on teh various vendors using JIRA and Confluence Collaboration tools as well as grant users access to Ticketing System.

Confidential, Trenton, NJ

Business Analyst

Responsibilities:

• Gathered, analysed, documented business and technical requirements from both formal and informal sessions and validate teh needs of teh business stakeholders.
• Collecting metrics for teh scalability measurements for each application from teh business and responsible for preparing teh Requirement Specification Document.
• Analyzing teh Program Requirements Document (PRD) with teh halp of Value-Function and Quality. Facilitate process for requirements validation that follows teh MITA process/sub-process business model.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Involved in teh project for implementing Best Practices for Business Analysis in teh organization and instrumental in teh transition plan for Agile Development methodology using SCRUM.
• Responsible for checking member eligibility, provider enrolment, member enrolment for Medicaid claims in compliance with HIPAA guidelines.
• Documented theAS IS Process workflow, Investigation report, Data Gap Analysis, Data Mapping, Cost Benefit Analysis, Business Requirement Document BRD, Functional Requirement Document FRD and Minutes of teh meeting MoM
• Data mapping, logical data modelling, created Class diagrams and ER diagrams and used SQL queries to filter data within teh Oracle database.
• Modification or enhancement related to MMIS (Medicaid Management Information System) security.
• Formulated system design, methods, procedures, policies, and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes such as HIPAA/ EDI formats and accredited standards.
• Conducted Requirement Gathering sessions and business requirementsBRD, Functional requirementsFRD, Request for ProposalsRFP, General System Design, Training Documents
• Organized and facilitated Agile and Scrum meetings, which included Sprint planning, Daily Scrums or standups, Sprint Review and Sprint Retrospective.
• Create and maintain product backlog items, bugs, features, etc. in JIRA and TFS / Azure DevOps for story tracking and documentation.
• Responsible for defining teh scope and implementing business for healthrules of teh project, gathering business requirements and documentation.
• Identified/documented data sources and transformation of Healthrules required populating and maintaining data warehouse content.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, healthrules, and information needs. Ensured that critical requirements are not missed.
• Understand of healthrules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI).
• Conducted internal audits and prepares audits reports to ensure compliance with Medicare, Medicaid, and other institutions.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS. Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Employed UML methodology in creating UML Diagrams such as Use Cases, Sequence Diagrams, State Diagrams, Activity Diagrams and business process and workflows.
• Used MMIS - Medicaid Management Information System for Insurance Claims Filing and patient information using MITA - Medicaid Information Technology Architecture as a platform.
• Extensively used SAS administration skills for managing and modifying metadata server setup/structure, creating new data sources, data libraries, and user groups
• Provide technical leadership in adopting new technologies and processes that promote efficiency and quality. Implement Build/Release Engineering (DevOps) methodologies and standards. Implement monitoring solutions
• Identified and developed Use Cases from teh business and systems requirements. Documented high level and detailed Use Cases to include all teh functionalities of teh new system.
• Produced Initial Medicaid Information Technology Architecture (MITA) State Self-Assessment Report to support teh current Medicaid Management Information System (MMIS) Replacement Project.
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Assisted quality assurance team to functional-test teh new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data

Confidential, Long Beach, California

Business Analyst

Responsibilities:

• Responsible for integrating with QNXT. Designing test scripts for testing of Claims in Development, Integration, and production environment.
• Prepared test cases for data validations between Data Mart to data cubes.
• Involve in analysing defects that have been reported in teh JIRA and sending them over to teh developers for a fix.
• Performed teh requirement analysis, impact analysis and documented teh requirements using Rational Requisite Pro and Utilized Agile experience with large and small teams
• Assist with training of clients QNXT configuration team on applications and best practices for both Medicare and Medicaid products.
• Worked with claims and configuration departments to resolve and reduce provider issues by analysing and researching Medicare and Medicaid guidelines, fee schedules, and provider credentialing, contracting, and licensing requirements
• Add a comment to teh JIRA that need more Clarification if teh Business Owner is not reflected in teh JIRA.
• Involved with data profiling for multiple sources and answered complex business questions by providing data to business users.
• Analyse current configuration team SLA service level agreement and recommend more standard SLA across team members based on QNXT t noledge levels.
• Reviewed electronic edit check prior loading into clinical databases during database testing (UAT). Performed Data validation.
• Experience with TriZetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Designed and implemented SQL queries using joins, unions, outer joins, group by and aggregate functions to extract data from different databases (Oracle, SQL Server) for timely reporting and Validation.
• Use JIRA to track and report defects to developers. Before Logging teh Defect, working with BA people to find out any requirement changes.
• Write SQL scripts for adding, changing, or deleting various benefit or contract data to or from QNXT that would take several ma hours to complete via teh front-end software.
• Attended requirements gathering sessions with teh customer based on user feedback and new enhancements, which were entered into JIRA and tracked for future releases.