SUMMARY

• Business Analyst with 8+ years of proven skills in for requirement gathering, interacting with developers, documenting various business processes, coordinating various projects within healthcare.
• Experienced in interfacing with stakeholders and senior management with excellent communication and interpersonal skills.
• Experienced working in Medicare and Medicaid projects.
• Excellent knowledge ofHealth Insurance Portabilityand Accountability Act(HIPAA) transaction and code set rules such asEDI 837,270,271,276,277,834,835.
• Proficient in ICD - 9-CMandICD -10-CMcoding and claims processing.
• Involved in working at all stages of system developmentLife Cycle. Extensiveexperience leading, facilitating conductingJoint Application Development (JAD)sessions among user community, stake holders and technical management, creating project plans and schedules and managing changes.
• Analyzed and synthesized results fromJoint Application Development (JAD),proposed alternative tasks and transformed those into Business Requirement Document (BRD).
• Experience in using methodologies such asUML(Unified Modeling Language), OOAD (Object Oriented Analysis and Design) andAPM(Agile Project Management).
• Experience usingRational RoseandMS Visiofor businessprocess modelingand designingdata flow diagrams (DFD).
• Expertise in writingRequirements,Test Plansand Test Cases.
• Prepared Functional Specification Documents,AS-ISandTO-BEworkflows.
• Well versed with both Agile and Waterfall SDLC processes.
• Thorough knowledge in Requirement analysis,Planning,Scheduling&Trackingprojects.
• Concrete understanding ofBusiness Requirement gathering,Business Process flow,Business Process ModelingandAnalysis, design documentation.
• Strong problem solving and analytical skills with in-depth understanding of system development methodologies, techniques and tools.
• Work with the development team to provide an environment ready for testers and end-users.
• Facilitatedtest plan/test casewalk-throughs for thebusiness and development teamsto obtain feedback and/or approval sign-off.
• Excellentorganizational,interpersonal, communications, teamwork with proven skill to interact across multiple levels of organization.
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio.
• Liaise between business and technical personnel to ensure a mutual understanding of processes and applications.
• Knowledge of HL7 and/or X12 standards, segments and fields required
• Good Understanding of Healthcare standards: HL7 2.x, CCD, CDA, FHIR and ICD-9/10.
• Extensively worked with different X12 Hierarchical Levels (HL structures) in various inbound claim/inquiry-response transactions (837 P/I/D, 270/271, 276/277).
• Worked on development and implementation of policies, procedures and QA methodologies
• Gathered requirements to check HIPPA- eligible & participation check for individual coverage.
• Technical and business knowledge in multiple disciplines/processes.
• Strong understanding of HIPAA Transactions & Code Sets Standards.
• Experience in executing Test Cases to test the application functionality against the requirements manually.
• Excellent skills in Business Analysis, Data Analysis, Requirement Analysis, Business Modeling and Use Case Development using UML methodology, Project Management Methodologies include, SDLC, and Waterfall
• Excellent communication and presentation skills. Experience working with business user as well as senior management

TECHNICAL SKILLS

Project Methodologies: AGILE/ SCRUM, Jira, Confluence, Waterfall and Rational Unified Process (RUP)

Project Tracking Tools: MS Project, JIRA, Rally, IBM Rational Clear Quest

Microsoft Tools: Word, Excel (Pivot Tables), Power Point, One Note, Outlook, MS Access

Database Tools: SQL Server, Oracle, PLSQL

Business Analysis Tools: UML, Balsamiq, MS Visio, Lucid chart, Tableau, SharePoint

Business Artifacts: Project Charter, BRD (Business Requirement Document), FRD (Functional Requirement Document), SRD or SSD (Software Specifications Document), Risk Management, Mockups, Use cases, Activity Diagrams and RTM (Requirement Traceability Matrix)

EDI Healthcare Transactions: 834 (Memberships), 835 (Payments from Payer), 837p (Professional Billing), 837i (Institutional Billing), 4010, 5010, 270, 271, 276, 277, 278

Healthcare: FACETS, HIPAA, Medicare, Medicaid, ICD 9, ICD 10, Claims Adjudication, EMR, EHR, COB and EOB

PROFESSIONAL EXPERIENCE

Confidential - Dallas, TX

Business Systems Analyst

Responsibilities:

• Identify and reconcile errors in client data to ensure accurate business requirements.
• Draft and maintain business requirements and align them with functional and technical requirements.
• Worked with Subject Matter Expert from different functional areas to define requirements specification.
• Created and Maintained Requirement documents for 270/271(inquire/response health care benefits), 834(Benefit enrollment- HMO, PPO, Medicare, Medicaid, Group), 837(Health care claim)
• Facilitated Joint Application Development (JAD) Sessions for communicating and managing expectations involved in FACETS Implementation, involved end to end analysis of FACETS Billing, Claim Processing and Subscriber/Member module
• Analyze medical and claim data from various EMR/EHR, PDS (Practical Data Solutions) and PMS (practice management software) systems.
• Conducted impact analysis on AS IS system, identified impacted business and functional areas, including policy changes, web interfaces, database changes, claims process and reports changes.
• Conducted User Acceptance Testing with stakeholders and system users to uncover latent defects in the system. The defects were corrected and verified through a new cycle of regression testing.
• Maximized software efficiencies for hospital end users by utilizing the Medical Terminology knowledge to lower cost of care and reducing stays caused by adverse events.
• Used the Agile methodology to build the different phases of Software development lifecycle. (SDLC)
• Created test plan, test cases to validate solutions against requirements and initiated and executed User Acceptance Testing (UAT).
• Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
• Worked to configure following EDI transaction 277, 837I, P &D, 834.
• Ensure all the staff and the EMR are compliant to HIPAA regulatory and compliance requirements.
• Validated various applications with Memberships of Enrollment, Cancellation, Termination, Reinstatement etc. for commercial, Medical and Billing in Facets.
• Performed Gap Analysis and created test plans for clients for conversion from data collection to EMR solution.
• Design, analyze and performed Integration and wrote System requirements on different leading health care software’s such as FACETS
• Worked as a User/Customer advocate and negotiated with user as well as the technical team and management staff to resolve any outstanding requirement conflict during the whole SDLC process.
• Conducted reporting requirements from the data ware house and analyzed the tables and columns to be added in the oracle data ware house from the SQL server.
• Worked on Agile Methodologies to implement the project.

Confidential -Richardson, TX

Business Analyst

Responsibilities:

• Gathered requirement through workshops and JAD sessions.
• Conduct gap analysis between the current system and new requirements to be implemented thereby mapping the business requirements to the application
• Involved in training and test session on HIPAA Privacy policy.
• Prepared high level and detailed system requirements documents for the application.
• Actively participated in daily Stand Up meetings and Sprint Planning meetings
• Worked with internal stakeholders creating, prioritizing, and monitoring application feature/issue backlog.
• Created and maintained user stories using Jira.
• Analyzed HIPAA 5010 standards for 837P transactions, related to providers, payers, subscribers and other related entities
• Identified the requirements for accommodating HIPAA 5010 standards for 837P transactions and captured these requirements to develop new GUI for the internet-based application
• Managing and Billing Medicare, Commercial HMO/PPO claims daily.
• Involved in FACETS Implementation, involved end to end testing of FACETS Billing, Claim Processing and Subscriber/Member module.
• Extracted data from various sources using SQL queries as per the requirements.
• Used SQL queries to validate data sets.
• Set claim processing data for different Facets Module.
• Involved EDI Claim Process according to HIPAA compliance.
• Involved in daily Scrums to determine the status of the project and impediments if any
• Involved in sprint planning meeting to identify the tasks for the sprint and getting team members acceptance/commitment for the assigned tasks.
• Involved in Sprint review meeting with the team and stakeholders to review the achievements from the sprint and get approvals
• Identified the requirements that go in each sprint, collect them in the sprint backlog and collecting and managing the requirements that are not part of the current sprint into the product backlog
• Write high-level and low-level business requirements and design mock-up screens for the application
• Analyzed the existing data model and provided suggestions and recommendations
• Translated the requirements prepared for SDLC methodology to User Stories and implementing Agile methodology as a standard for the ongoing project
• Wrote user stories and acceptance criteria for the requirements of the project
• Involved in daily scrum meeting to discuss any roadblocks or impediments in the project path
• Involved in sprint planning session to identify the features and functionalities that should be achieved by the new application
• Preparing Requirements Traceability Matrix and Test cases to ensure the desired functionalities are present
• Identified various points of integration among the new and existing applications and required integration with other IT components
• Worked closely with the business team, development team and the quality assurance team to ensure that desired functionalities will be achieved by the application
• Provided business and technical suggestions and recommendations during the project life cycle
• Developed documents like BRD, FRD, Data specification document, technical specification documents, file transfer document, Data mapping document etc.
• Ensured the functionality meets business requirements as defined in test results logged in requirement management tool.
• Created Test Cases to test the functionality of the system based on the test conditions.
• Used Facets to receive 834 inbound files and processing of the files across different modules in the application
• Worked with Systems team for HIPAA Claims validation and verification process (Pre-Adjudication).
• Conducted claim validation and end/denied claims analysis for the health plans Medicaid programs.
• Maintained the EDI Inquiry Problem database including the evaluation of problems or issues through to resolution.
• Performed requirement tracing by mapping the use cases related to Test Case ids to get the status of the requirement.
• Conducted KT sessions for Member, Provider and Claims Ajudication.

Confidential - Dallas, TX

Business Analyst

Responsibilities:

• Coordinated requirements elicitation to extract business needs by liaising with key stakeholders.
• Strong functional expertise in the Healthcare Payer Area - Membership claims, benefits, eligibility check, ICD10,HIPAA, CMS HCPCS Exposure to Health Care Industry standards like HIPAA
• Participated in project meetings to support the team as required, organized various meeting with SME's and testing Team to ensure that we are on track with all of our deliverables, tracked all our deliverables on a daily basis by using Deliverables tracking Template.
• Teamed up with both internal and external software development teams to provide functional requirements specifications in the form of use cases, business process flows, and prototypes and management reporting requirements.
• Requirements Gathering & Analysis always ensured HIPAA Compliance Auditing
• Participated in creating Facets data model.
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)
• Performed Requirement Gathering by interacting with Business users and documented the requirements
• Worked with Business Users and Solution Engineers to solve the capture defects in the MMS system and to effectively solve them.
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Conducted JAD Sessions, Peer Review sessions with the SMEs, Solution Engineers, developers, Business users.
• Involved HIPAA regulations in Facets HIPAA privacy module.
• Worked with FACETS, e Billing and EDI HIPAA Claims (837/835/834) processing.
• Prepared the Business Workflow using MS-Visio with input, output, Pre-and Post-Conditions.
• Analyzed the scope of the project to review it with the customers for different review sessions of the application.
• Intensively involved in project testing efforts by doing System Integration Testing, Regression Testing and by helping UAT team in User Acceptance Testing
• Used to execute test cases for several transactions such as 837, 277, 276.
• Create SQL queries to read data from databases.
• Worked with the Testing team to test the system extensively and log defects.
• Defined the maps from the existing BizTalk solution and validated it with the client for any changes.
• Performed data mapping and tracing data from system to system in order to solve a given business or system problem.

Confidential

Business Analyst

Responsibilities:

• Gathered detailed business and technical requirements and participated in the definitions of business rules and data standards.
• Gather requirements by conducting meetings and brainstorming sessions with end users and SME and document them using Requisite Pro - the documentation tool offered by Rational
• Worked on Member Management, Eligibility, Claims, and Provider modules within Facets.
• Conducted extensive analysis on migration and conversion of Provider and Member data.
• Clarified QA team issues and reviewed Test Plans and Test Scripts developed by Development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Worked in Healthcare Claims Processing (837/835/834) includes facility claims and professional claims.
• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance
• ValidateEDI Claims Process according to HIPAA compliance.
• Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirements.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Performed claims adjudication using Facets.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 EDI (834, 837 standards)
• Created and maintained the Requirements Traceability Matrix (RTM).
• Used SQL queries to validate actual records with expected record data.
• Was responsible for tracking issues that are detected and updating the status of existing issues based on the daily meetings with the offshore team.
• Clear understanding of Medicare (Part A, Part B and Part D) and Medicaid benefits as well as business processing.
• Worked with project manager and other users and created workflow diagrams using MS Visio/UML.
• Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
• Worked directly with software engineers to ensure clear communications on requirements and defect reports.
• Was involved in Functional System Testing, Integration Testing, Regression Testing, and User Acceptance Test using the test cases given by the client before releasing the application.
• Involved in project status meetings, QA review meeting, and System Test meeting.
• Wrote test cases and test scripts for the User Acceptance testing.
• Performed User Acceptance Testing (UAT).
• Create SQL queries to read data from databases.
• Worked with the Testing team to test the system extensively and log defects.
• Defined the maps from the existing BizTalk solution and validated it with the client for any changes.
• Performed data mapping and tracing data from system to system in order to solve a given business or system problem.
• EDUCATION
• Bachelor of Commerce from Jiwaji University, Gwalior, Madhya Pradesh, India.
• Master of Commerce from Jiwaji University, Gwalior, Madhya Pradesh, India.
• Master in Business Administration in Human Resources from Jiwaji University, Gwalior, Madhya Pradesh, India.