SUMMARY

• Sr. Business Analyst with 8+ years of professional experience in Healthcare, Medical billing, Accounts Receivable, Health Insurance Portability, Accountability Act, EDI Transactions, HIPAA, MMIS, Medicare and Medicaid and hands - on experience in business process analysis, business requirements, database design, business process modeling and strategic planning.
• Extensive experience with Health and Human Services programs, Medicare, Medicaid MMIS, Child Welfare, HMO, PPO, POS, Managed Care, Life, Health Insurance Exchange HIX, Health Information Exchange HIE, HIPAA regulations, Electronic Health Records EHR, Electronic Medical Records EMR, and Electronic Patient Records EPR, SHBP (STATE HEALTH BENEFIT PLAN).
• Expert of all the phases of SDLC methodologies like Waterfall, Iterative, Rational Unified Process (RUP), Agile/SCRUM, Kanban throughout the project life cycle.
• Experienced in interacting with business users to identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), General system Design (GSD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project.
• Knowledge of big data technologies, Hadoop, Hive, Map Reduce, Azure, NoSQL, JavaScript, Linux, HTML, CSS, AWS, Salesforce Customer Relationship Management (CRM) platform.
• Experience working in multiple Relational databases like MySQL, Oracle, SQL server and in-depth knowledge in ETL tools (Pentaho, SSIS).
• Responsible for creating different sessions and workflows to load the data-to-Data Warehouse using Informatica Workflow Manager.
• Experience in working in close proximity with business users, project stakeholders, Subject Matter Experts (SMEs) to identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), General system Design (GSD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project. and minute level specifications for new applications, and to modify existing applications.
• Experience in supporting HL7, EDI interface projects. Interface design and build with Rhapsody interface engine. Rhapsody interface builds using Restful API, HL7, FHIR, ETL, JavaScript, MS - SQL, NoSQL and EDI. Linux, MS, Unix system administration.
• Experience in writing documents like Business Requirement Document (BRD), Functional Requirement Specification (FRS), Change requests, developed Use Case Diagrams, Activity Diagrams, and Business Flow Diagrams, Test confirmation criteria.
• Proficient in using applications such as Charles River, MS Word, PowerPoint and Excel; and data sources including Bloomberg, Reuters and FactSet.
• Proficient in developing & automating reports, iteratively building & prototype BI dashboards using Tableau to provide insights at scale, solving for analytical needs of business teams.
• Experienced in conducting GAP analysis, User Acceptance Testing (UAT), Risk Analysis and mitigation plan, Cost benefit analysis and ROI analysis.
• Exposed to Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
• Experienced in FACETS and its modules such as Claim, Member/Subscriber, Billing, Provider, Medicare, Medicaid and experienced with several Facets Batches.
• Extensive knowledge Qualified Health Plans (QHP), Qualified Dental Plans QDPs, Health Insurance Exchange (HIX) and Affordable care Act (ACA)and Patient Protection and Affordable Care Act (PPACA).
• Experience in Revenue Cycle Management (RCM) for Scheduling, registration, eligibility, authorization, claims processing and payment.
• Extensive experience in Business Analysis to Translate EDI requirements into functional specifications, create companion guides using Edifecs Spec builder, and develop logical mapping for Gentran/ ECMap/ GIS-SAP Idoc/ Mainframes
• Proficient in Developing and executing Test Plans, Test Case, FRD and Medical Billing, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
• Adequate knowledge in Health Administration - Claim’s processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Confidential, Medicaid, CDHP (consumer driven health plans).
• Extensive Claim experience for Provider, Payer, Clearinghouses, Pharmacy Expert level knowledge of healthcare industry applications and processing, EDI transaction sets and formats.
• Excellent knowledge of Medicare Part A, B, C and D and Medicaid Health Insurance Policies like CHIP, Personal Injury Protection PIP insurance, billing experience in life and disability in health plans etc.

PROFESSIONAL EXPERIENCE

Sr. Business Analyst

Confidential - Phoenix, AZ

Responsibilities:

• Validated Active Renewals and Passive Renewals for “Qualified Health Plan (QHP)” and “Medicaid” (MCD) Members based on their effective plan dates.
• Gathered requirements for making changes to the existing Electronic Medical Records (EMR), Electronic Health Records (EHR) and Ambulatory Services for the existing Epic Interfaces.
• Involved in administering HMO, PPO, HSA, POS, EPO, FFS, DSNIP and Medicare Supplemental (Medigap) contracts.
• Developed EDI specifications and applications structures for data feeds and mappings for integration between various systems, including XML and performed back-end testing on the Oracle database by writing SQL queries
• In depth knowledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of the training program to vendors.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Identified/documented data sources and transformation rules required to populate and maintain data warehouse content.
• Involved in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from a Operational Data Store to an Enterprise Data Warehouse.
• Agile projects designed to improve the current claims adjudication processing application MQ Direct.
• Conducted walkthrough of BRD in the JAD Sessions with users and developers. Collected specific information to include in the Functional Requirements Document FRD.
• Used HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Well versed with HIPAA, Facets, CHIP claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Analyzed federal and state regulations/ policies for Medicaid and Children’s Health Insurance Program (CHIP) reimbursements.
• Worked on Medicaid and CHIP program requirements, including complete end to end life cycle data flow of eligibility, enrollment, claims, encounters, payment and post-payment.
• Conducted multiple JAD sessions between various organizations such as DHS, DCCA, and OIMT to elicit system requirements using stakeholder analysis, RACI chart and prototypes.
• Well-coordinated with the team and maintained independent workload of several Programs including Medicaid, SNAP, TANF, CHIP, Presumptive eligibility and ACA.
• Responsible for delivering recommendations in establishing data exchanges between the State's Medicaid Management Information System (MMIS) and the Federally Facilitated Exchange (FFE) via the Federal Health Information Exchange (HIX) Hub for Affordable Care Act (ACA) requirements.
• Committed to establishing FFM / FFE (Federal facilitate Exchange) under HIX (Health Insurance Exchange) that meet the functional requirements of Patient Protection and Affordable Care Act (PPACA).
• Involved in creating EDI Specifications, Test plans and for the 837 Institutional, 837 Professional, 835, 270/271, 276/277, EDI transactions with EDIFECS.
• Used FACETS to provide seamless transactions between the provider, members and the plan.
• Did GAP analysis by comparing the past HIX reports with present Contractual Reports to create the Future Reports.
• Validated member Eligibility, benefit and claim status in a system and parallel testing.
• Worked and supported on EDI Translators to analyze EDI files submission for Professional, Inpatient, Outpatient, pharmacy claims and dental claims.
• Firm understanding of HIPAA regulations and experience working in all phases of healthcare insurance processing like defining Membership Eligibility and Enrollment and various Medical Claims processing.
• Validated and processed healthcare transactions across all channels in multiple formats using edifices.
• Developed and presented CMS stakeholder presentation to share MDM solution before deployment to production.

Sr. Business Analyst

Confidential - Sioux Falls, SD

Responsibilities:

• Completed Agile/SCRUM project to allow a direct exchange method to send and receive secure patient EMR data between care providers to support coordinated care.
• Organized and facilitated JAD sessions as part ofRequirementelicitationsessions based on User Stories and identifyingBusinessand FunctionalRequirementand detailed discussions
• Assisted with DHS complaints and resolution by effectively communicating with key stakeholders and working with internal departments
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA)
• Extensively used SQL queries for data validation in both Medicare/Medicaid and commercial HIX
• Develop, test, modify and manage EDI (x12 standard) maps using B2B mapping tools in the Healthcare industry.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claim’s module.
• Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999 HIPAA EDI Transactions using MS Word, MS Excel, MS Access and Facets PROD PPMO
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Developed business and functional requirements for the National Provider Identifier NPI Crosswalk and Crossover Claims Crosswalk solution.
• Assisted technical teams in creating ER Diagrams; wrote complex SQL Queries for Data Analysis; well versed with Data Modeling, Data Flow diagrams, System Architecture, User-Interface design, Data Warehouse, RDBMS.
• Created DTS and SSIS Packages to vendors in which records were loaded Daily, also to other data resources such as Excel, Access, flat file, and XML in order to Create and maintain a centralized data warehouse.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Working on Pharmacy Claims/Rx claims, Claims adjudication, Eligibility, Prior Authorization, Accumulators, Drug Step edits, PHI and different managed care products like POS, HMO and PPO.
• Worked with the various Claims Transactions such as: 837 submit medical claims, 835 medical claim payments, 270 benefit/eligibility inquiry, 271 benefit/eligibility response, 276 claim status request, 277 claim status notification, 820 premium payments, and 834 enrollments.
• Involved in developing the new child only pediatric QHP compliant QDP plans and adult dental insurance products for the IU65 segment on and off exchange.
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships
• Worked on Medicare Advantage (A, B, C), Medicare Part D (MA-PD), Medicaid Options (Under 65 and Over 65) and Managed Care (Care, Disease & Case Management and in Insurance regulations & Claims Processing).
• Validation of connectivity between the external systems and CMS Confidential database for electronic submission of documents by verifying the gateway logs and SAML assertions.

Business Analyst

Confidential - Rochester, MN

Responsibilities:

• Worked extensively on Claim’s adjudication and Claims Payment functional area with the Subject Matter Experts and gained strong knowledge.
• Developed Traceability Matrix including BRD and FRD to track down different defects related to Member enrollment eligibility, Claims adjudication, Clinical request from members.
• Analyzed the conformance of the Commercial off the Shelf COTS product with the CMS guidelines Guidance for Exchange and Medicaid Information Technology IT Systems for enrollment eligibility.
• Gathered requirements for Medicaid and CHIP insurance coverage and performed data analyses.
• Participated in defining new processes for interfacing with DHS for Medicaid claims submission.
• Monitored all Affordable Care Act regulations to create client briefs and libraries for PPACA compliance.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Business Analyst for a large Electronic Health Records EHR System and Design project related to State of California HER and HIX standards - DHCS.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims.
• Analyzed issues with EDI transactions and fixed IDOCs to be submitted into SAP for order fulfillment.
• Documented various key elements of HIPAA compliance and made sure that they were understood by the development teams and ensured that the test cases written for the project were HIPAA complaint.
• Adjudicated medical claims for correct pricing to administer payment to medical providers.
• Involved in assembling, organizing and analyzing patient information, including medical history, symptoms, examination results, test results and prior treatments for HER (HL7) software development.
• Responsibilities include researching a quicker and more efficient way to implement HL7 interfaces by using FHIR (Fast Healthcare Interoperability Resources) Specification, which is a standard for exchanging healthcare information electronically.
• Performed 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.
• Developed Health Plan Issuer Accreditation Mapping to Qualified Health Plan (QHP) and Qualified Dental Plans QDPs.
• Followed the Agile Scrum SDLC (System Development Life Cycle) methodology, Validated QHP Benefits, Rates, Network Adequacy, Essential Community Providers, Prescription Drugs and Service area Information with their templates for data submission by insures.
• Experience in Claims Processing, claim encounters and Claims Scrubbing in HMO, PPO, DSNIP, Medicaid and Medicare.
• Worked on Facets including Claim processing online and batch adjudication, Case management, Customer service, Member/subscriber administration, Provider network management and reporting.
• Responsible for the development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837.
• Worked closely on adherence to HIPAA compliance, meeting CDC and CMS requirements to meet the needs of implementation projects.
• Ensured all EDI Claims are received from Trading Partners and they are processed and loaded into its appropriate claim systems daily.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Active member for the policy review to implement the blueprint requirements for Medicaid/MMIS, Medicare, CHIP and Tax Credits benefits per CMS guidelines.
• Designed and Developed various Business Intelligence reports against ODS, Claims systems such as Facets, HER systems such as NEXTGEN and Care Management systems, Network Management systems, Revenue Cycle Management systems.

Business Analyst

Confidential - Salt Lake City, UT

Responsibilities:

• Gathered requirements as well as scheduling a daily scrum meeting to elicit, analyze, verify, and manage the needs of the project stakeholders, customers and end users.
• Organized and facilitated Agile and Scrum meetings, which included Sprint Planning, Daily Scrums or Standups, Sprint Check-In, Sprint Review & Retrospective.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables
• Created SQL Queries using Oracle and SQL Server in validating data into Data Warehouse/ETL applications
• Conduct JAD sessions to gather and document requirements that enhance a wide range of functionalities including claims processing, eligibility and enrollment, provider networks, and electronic data interchange.
• Responsible for analyzing Eligibility for State Welfare Program, Children’s Health Insurance Program (S-CHIP), Food Stamps (SNAP), Child Care and Temporary Assistance to Needy Families (TANF) (CHIP, SNAP, and TANF).
• Worked on electronic Medicaid eligibility verification system and the Medicaid and Medicare intermediary along with their roles in claim processing.
• Performed SQL queries and create test cases to obtain accurate claim data for both manual and automation testing for the Amis’s Application upgrade Financial Data Warehouse for all claim information.
• Managed the development of SQL based test cases with Test Team for Data Warehouse testing effort.
• Helped the team to convert Confidential Benefit Plan (SHBP) current database to a DB2 database.
• Participated in Requirement gathering, Business Analysis, User meetings with both onshore and offshore team, discussing the issues to be resolved and translating user inputs into ETL design documents along with capturing specific data and analysis of the root cause of the problem.
• Analyzed Service Requests and Change Requests available in JIRA and pertaining to everyday business need
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 834, 837, 835, and 270/271
• Involved in developing and executing Test Plans, Test Case, FRD, TriZetto Facets 4.x and Medical Billing, Test Scenarios, also performing functional, usability testing and ensuring that the software meets the system Requirement.
• Worked as liaison between software developers and users of EMR systems to create better electronic medical record systems.
• Tested claims adjudication and group and enrollment in for new Medicare advantage members.
• Served as an active member of the PDP team, interacting with developers, business users and subject matter experts SME to analyze and configure PBM Web-Portal functionality based on Business Requirement.
• Documented the UAT Plan and worked with the UAT Team to ensure the acceptance criteria for every requirement has been included in the UAT task plan.
• Collaborated with the IT Data Modeling team to ensure data model design is consistent and accurate with the business requirements.
• Responsible for Medicaid Claims Resolution/Reimbursement for state healthcare plans using MMIS and Managing and Billing Medicare, Commercial HMO/PPO claims daily.
• Worked on the claims related to Medicare (Part A, Part B, Part C, Part D).
• Performed extensive Requirement analysis and developed use cases and workflows.

Business Analyst

Confidential - Minneapolis, MN

Responsibilities:

• Successfully collaborates with business stakeholders and Sponsors to capture requirements for new development projects. Manages requirements and resources through the SDLC.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI x12 Transaction, Code set and Identifier aspects of HIPAA.
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Develops business requirements and related technical documentation based on needs of various Divisions and Offices within DHS via industry standard techniques such as data modeling, workflow analysis, reverse engineering or requirements decomposition.
• Created Use-Cases and Requirements documents to document business needs and involved in creating use cases based on HIPAA standards.
• Provided Database support that includes activities required to correct, delete or summarize medical history of members as well as provider information.
• Worked with marketing communication and provided group/subscriber information for mandates communication.
• Worked with the implementation and ongoing support of the Health Insurance Exchange (HIX) and compliance with Affordable Care Act (ACA) mandate and Health Care Reform Act.
• Practiced agile methodology, lead sprints and prioritize line items based on key business initiatives with respect to the Affordable Care Act (ACA) mandate and Health Care Reform Act.
• Involved in projects to design a state-customized Financial Management solution for Health Insurance Exchange (HIX)
• Committed to establishing FFM/FFE (Federal facilitate Exchange) under HIX (Health Insurance Exchange) that meet the functional requirements of Patient Protection and Affordable Care Act (PPACA)
• EDI Claims Processing documented enhancements to the EDI Claims Processes EDI 837, 835, 276, 277 to ensure accurate processing of claims of members.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Tested the billing and rendering provider, member subscriber, and payment modules of FACETS in the UI as well as in terms of database validation through SQL Queries.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Involved in Medicaid and Medicare claims processing along with CMS, MITA, MMIS, Electronic Medical Health Record (EMR/EHR) and Pharmacy Benefit Management (PBM).
• Setting up Fee Definition and Fee Calculation in FACETS for QHP Individuals, Grandfathered/ Transitional Small Group, QHP Small Group and Large Groups
• Involved in Testing of the various results generated by the reports against the data present in the database tables and used UAT on that data involving the users.
• Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.