SUMMARY

• Around 8+ years of experience in systems and Business analysis in Health care, Claims Management Systems Medicaid and Medicare Services.
• Insightful noledge of business process analysis and design, domain & technology expertise wif strong integration skills.
• Experienced as a Business Systems Analyst in gathering the business requirements from the existing stored procedures, supporting the Interfaces and reports development in explaining the functional requirements, proposing technical solutions, supporting the unit testing and system integration testing wif the functional flow.
• Strong experience in Waterfall, Agile and Scrum.
• Hands on experience in analyzing and documenting Business Requirements Documents (BRD), Functional Requirements Documents, Use Cases and Requirements Traceability Matrix (RTM).
• Strong noledge of HIPAA standards 4010, 5010, ICD - 9, ICD-10, EDI, EMR/EHR.
• Develop different EDI healthcare transactions like 837 for submitting claims, 835 for payments, 834 for benefit enrollment, 270, 271 for health care benefits and eligibility, 276, 277 for claims status and 278 for transmitting health care service information.
• Experienced on Claims, Payments, Medicaid, Medicare, Provider, Portal, and Benefits.
• Performed smoke test for 270/271 transaction of the HIPAA 5010 version, transactions focused on were 270,271,276,278,834, 835, and 837.
• Monitored EDI systems to ensure smooth processing of inbound and outbound transactions and provided technical support when needed.
• Extensive experience in modeling the “AS-IS” and “TO-BE” business processes and carryout Gap analysis
• Information and understanding in conducting Joint Application Development (JAD) and Rapid Application Development (RAD) sessions. Conducted Requirement Gathering Sessions and interviewed Subject Matter Experts, gatheird detailed functionality aspects of business process and updated the information to the requirements in an easily comprehensible format.
• Having extensive domain noledge in MMIS, EPIC, EDI X12, HL7, HIPAA, System, Medicare and Medicaid, CMS Compliances/Regulations.
• Broad experience in creating business process flow diagrams, UML (Unified Modeling Language) tools to create Activity, Sequence and Collaboration diagrams.
• Extensive involvement in data mapping using Facets data model.
• Expertise prioritizing, multitasking and managing multiple projects related to Medicare (Parts A, B, C, D) & Medicaid, EDI, HL - 7, CPT.
• Understanding of EDI business practice and the ability to understand the client's needs.
• Experience in writing SQL queries for Data Analysis and QA report testing.
• Business Analysis, Supporting Strategy management, Client relations, Business modeling, CRM & Workflow, Test planning MS Office, MS Project, MS Visio, MS Excel.
• Strong ability to analyze business problems and carry-out root cause analysis using various problem-solving tools & techniques
• Strong interpersonal skills, Analytical skills and Client facing experience
• Knowledgeable about preparing RTM documents and also Experience in conducting Impact Analysis.
• Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements.
• Excellent business communication and presentation skills. Adapt at creating, editing, and coordinating extensive communication networks, to keep executive staff and team members apprised of goals, project status, and resolving issues and conflicts.
• Knowledge of Life Insurance concepts including Adjustable death benefit and various flexibilities associated wif it.
• Conducted successful projects wif the help of teams to achieve deadlines timely and proficiently and worked on core payer system.
• Organized, goal-oriented, FRD, self-starter, and ability to master new technologies manage multiple tasks while following through from start to completion.
• Experienced in analysing business requirement at all stages of Software development of life cycle SDLC.

PROFESSIONAL EXPERIENCE

Confidential, NY

Business Analyst

Responsibilities:

• Strong noledge of Medicaid; and Medicaid Management Information Systems (MMIS)
• Assisted wif user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
• Maintained Requirement Traceability Matrix (RTM) and Utilize Project management tool for change requests and defect tracking.
• Conducted claims validation and Pend/Denied Claims Analysis for the Health plans Medicaid programs.
• Worked closely wif the technical team to look up for the best possible solution on requirements by keeping business needs and technical constraints in mind.
• Analyzed current business process flow by understanding preset business rules and conditions.
• Conducted formal interviews, Live Meetings and JAD sessions wif business users and SME’s.
• Conducted internal audits and prepares audits reports to ensure compliance wif Medicare, Medicaid and other institutions.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Created Business Process diagrams, Web-page mock-ups using MS Visio for acceptance from end users.
• Extensive use of Facets back-end tables and front-end application system for data validation purposes.
• Experience in Healthcare Application Facets in different modules like Claims, Membership, Provider and Billing.
• Exposed to Medicare and Medicaid MMIS domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology.
• Defined project milestones, schedules, and monitored progress using MS-Project and updated plans as required.
• HIPAA Transactions mapping experience and in-depth noledge of HIPAA framework. Strong experience transacting wif Healthcare EDI standards - ANSI X12 v 5010 /837,, 276/277 BPML and -XML formats
• Analyzed and tested Data Interface needs wif external systems.
• Analyzed, manipulated and updated the Database using SQL.
• Worked on EDI Portal from its inception to completion and then support it.
• Involved in EDI transactions Analysis, Design, Implementation and Documentation
• Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions including 837, 276, 277, transactions.
• Associated wif full HIPAA Compliance life-cycle from gap analysis, mapping, and implementation and testing for processing of Medicare, Medicaid claims.
• Conducted Gap Analysis to analyze the client’s applications programs to determine the impact of the HIPAA final rule on EDI Transaction
• Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance.
• Worked on Member grouping, Member Contract, and Provider Contract using Facets.
• Conducted GAP Analysis & Data mapping for implementation.

Environment: Windows 2000, MS Word, MS Excel, MS Project, MS Visio, HTML, XML, Java.

Confidential, Delmar, NY

Business Analyst

Responsibilities:

• Implemented the SDLC for the developing life cycle and followed the standards process in the application.
• Interacted wif healthcare clients to gather requirements, objectives, and input and output requirements.
• Developed test cases and scripts for front end testing.
• Performed execution of test cases manually to verify expected results.
• Ensured the accuracy and consistency of the data during the data loading process.
• Developed Use case, Functional, Object diagrams using MS Visio.
• Reviewed design documents & business requirements to learn the function and scope of the application.
• Mapped the various loops, segments, and elements as a part of the X12 mapping for the member, provider.
• Involved in Procedure code mapping process.
• Healthcare EDI File noledge, ANSI X12 (270, 271, 837, 835, 834 & 999).
• Use Electronic Data Interchange (EDI) codes for verifying patient eligibility and receiving the insurance benefits, patient information, health care claim request, and healthcare claim through the new EHR System.
• Was involved in managing the Daily Standup meetings and also ensured that quality standards were enforced as per the build-release schedule.
• Worked wif various business professionals in understanding operational risks and risk reporting processes
• Developed a detailed test strategy, test plan and test cases to cover all the requirements.
• Developed Flowchart and process diagram using Microsoft Visio.
• Frequently communicated wif developers to resolve technical issues.
• Strong Experience & Expertise in Healthcare Payer - EDI(X-12 EDI Transactions like 837 Claims, 835, 997 Acnoledgements, 834 - Member Eligibility, 270/271 Eligibility Inquiry, 276/277 - Claims inquiry)
• Worked wif claims and configuration departments to resolve and reduce provider issues by analyzing and researching Medicare and Medicaid guidelines, fee schedules, and provider credentialing, contracting and licensing requirements
• Generated Business Requirement documents (BRD), Functional Specification design documents
• Reporting Analyst responsible for gathering reporting requirements from the business, developing reports in SQL, Ad Hoc reports and dashboards presenting reports to the business users.
• Managed technical documentation of website for content design. Used advanced formatting features of WordPerfect and MS-Word and MS Office, including Styles, Master Documents, and other formatting features to make professional printed documents.
• Worked on developing the business requirement for FACETS batch process for query response.
• Extensive involvement in data mapping using Facets data model.
• Integration specifications documents in Visio and conducted gap analysis of new implementations
• Elicited demands from the stakeholders and analyzed them for consistency, flexibility and completeness.
• Conducted JAD sessions wif Subject Matter Experts to obtain domain level information.
• Presented and conducted functional requirement reviews and walkthroughs wif the designers, developers, and stakeholders.
• Wrote SQL scripts for creating performance evaluation reports
• Identified Use Cases from Business Requirements and created UML diagrams like use case diagram and activity diagram using MS-Visio for various stakeholders.
• Analyzed the existing reports of the reporting system in the database. Checked the consistency of the data after ETL process using SQL queries.
• Worked wif HIPAA compliant ANSI X12 834, 837 formats for both professional claims and institutional claims.
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.

Environment: Agile (Scrum), HIPAA (5010), Microsoft Project, Java, MS Visio, Word, Excel.

Confidential, Arlington, Texas

Business Analyst

Responsibilities:

• Analyzed and document Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Translated the EDI X12 data into XML format for initial transformation/migration.
• Reloaded multiple business rules from the Legacy System into the new system.
• Worked on various Business and technical documents including the Requirements and Specifications.
• Worked on Child Support Obligations and benefits and prepared process flows and data flow diagrams.
• Wrote test plan, test cases for testing Medicare system.
• Coordinated wif the developer’s team to make sure the systems are running efficiently.
• Prepared reports, and submitted it to higher authority.
• Developed Functional Requirement Scenarios and Use Cased based on business needs.
• Involved in gathering Data Mapping Requirements from Technical Team.
• Worked wif Business user to define Functional Requirements and Business Process Flows.
• Developed Business Requirement Document (BRD) and Use Case Document (UCD) using Microsoft Office.
• Worked wif trading partners to implement and troubleshoot connectivity to EDI systems that included Secure FTP, for batch transactions and Web services for real time transactions.
• Documented Functional Specifications for Enrolment 834, Health Care Claim Payment and Claim 837, and Authorized Representative for Medicaid Members.
• Worked wif data migration and file mapping for various EDI transactions.
• In the Retiree Solutions Team for Medicare Part D, the focus is on ensuring that the EOB Explanation of Benefits content, computation and reporting satisfy Client needs and remain compliant wif all CMS mandates.
• Enhanced the Provider/Patient verification criteria using additional parameters based on the information retrieved from the EDI 837 me/P transaction files.
• Involved in integration of FACETS wif legacy and third-party vendor applications.
• Actively participated in Change Board Meeting for any changes in the business requirements.
• Updated BRD based on Change Request and manage Change Request Document using Microsoft Office.
• Used Quality Center to import all Defined Requirements from Microsoft Word.
• Worked wif Quality Analyst to ensure the validation of the system.
• Documented all the development work submitted to the client in a report format.

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, MS Office, SQL Server, Agile, MS Project, MS Access, EDI, Documentum 2.0. UML.

Confidential, Dallas, TX

Business Analyst

Responsibilities:

• Expertise in the EPIC Medical software application (EMR, HER) as it relates to hospital work ows and setting up the infrastructure for a software implementation in a clinic environment.
• Currently leading, coordinating EMR/EHR (me Helix 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 helix inpatient EMR for Stage 1 meaningful use clinical quality measure calculation by using Cypress tool.
• As Interface Architect designed and developed Admission, Scheduling Charge messages ow and transformations for 50 applications such as Dietary, Oncology, Radiology, Professional Billing, Operating Room, materials management, HIM Coding, Lab, External Partner EMRs additional Hospital Billing Systems, and HIEs
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Maintaining noledge of Medicare and Medicaid rules and regulations and evaluating the impact of proposed changes in rules and regulations.
• Created Process Work Flows and responsible for preparing Functional Requirement Speci cations Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming & developing questionnaires
• E ciently worked alongside Project Manager and Lead Business Analyst to determine the Scope and utilized Rational Uni ed Process (RUP) and Agile (Scrum) System Development Life Cycle (SDLC) methodologies to coordinate and strategize concise solutions wifin a constricted timeframe involving multiple interfaces.
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Developed, designed & implemented department plan to con gure new Facets integrated processing system, to include but not limited to, work ow, management oversight and performance analysis.
• Translated business requirements into functional speci cations and documented the work processes and information ows of the organization
• Performed felid-by- eld mapping of interface between parent EMR system and downstream system.
• Worked on the Patient Management System (integrated version of Patient Information System wif EMR/EHR)) is intended to remotely communicate wif a compatible pulse generator from BSC CRM and transfer data to a central database (HIT EHR).
• Expertise in Facets extension development, Facets Testing, Facets Interfacing
• Has exposure in the Design, development and maintenance of commercial projects using Waterfall Model and Agile Model.
• Agile and Waterfall methodologies were present and identi ed de ciencies, created a de ned business cases, and upon approval, implemented strategies for the department and adjacent teams.

Environment: PL/SQL, SQL Server, XML, Windows, Internet Explorer and Netscape, Web Logic, UNIX, Rational Req. pro, clear case, Rational Rose, Clear Quest, UML, MS Visio, MS Project.