PROFESSIONAL SUMMARY

• A result oriented individual with over 10 years of diversified experience in Healthcare, Medicare and Pharmaceuticals industry.
• Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.
• Expertise in translating user requirements into technical specifications and mapping the process design, work flows for SDLC with documenting and managing business requirements.
• Possess excellent organizational, interpersonal, communication and documentation skills with good process management skills along with a remarkable ability to gather requirements to bring out quality product.
• Experienced working with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using General equivalence Mappings GEM .
• Strong understanding and working knowledge of MMIS subsystems like Claims, Pre Admission Screening, EDI, TPI.
• Experienced with ICD09 and ICD10 systems.
• Requirement gathering through interviews, workshops, JAD sessions with clients, developers and QA Analysts and referring to existing system documentation and procedures.
• Experience in developing of web-based applications
• Worked with MEDICARE, MEDICAID and FACETS upgrade from 4.7 to 5.01 claims systems.
• Extensively worked with different X12 Hierarchical Levels HL structures in various inbound claim/inquiry-response transactions 837 P/I/D, 270/271, 276/277 .
• Experience with Business Objects to test Reports.
• Involved in testing HIPAA Database, which incorporates all the HIPAA Health Insurance Portability and Accountability Act transaction sets
• Gathered requirements to check HIPPA- eligible participation check for individual coverage.
• Strong understanding of HIPAA Transactions Code Sets Standards like 820- Premium Payment for enrolled health plan members, 834- Enrollment /Dis-enrollment to a health plan, 835, 837 ...etc.
• Possess strong analytical and problem solving skills with the ability to adapt to a new environment and meet stringent deadlines.
• Ability to successfully manage multiple deadlines and multiple projects effectively through a combination of business and technical skills.
• Expertise in translating user requirements into technical specifications and mapping the process design, work flows for SDLC with documenting and managing business requirements.
• Involved in creating test scripts and test data files for the HIPAA transaction based on the ANSI X12N HIPAA standards
• Professional expertise in MS Office, MS Access, MS Sharepoint and MS Project.
• Have gathered requirements in compliance with HIPAA, Knowledge of HIPAA 4010 and 5010 transaction standards.
• Highly motivated worthy team player capable enough to work and lead within a team environment besides being capable to work independently.
• Strong business analysis skills and thorough understanding of software development life cycle.
• Strong ability to understand and document critical data through effective data collection, data analysis and data interpretation.

TECHNICAL SKILLS

• Methodologies: UML, RAD, RUP, JAD, Agile
• Requirement Tracking: Rational RequisitePro
• Change Management Tools: Rational Clear Quest, Test
• Performance Testing Tools: Rational Suite Performance Studio
• Operating Systems: MS Windows 7/XP,
• Databases: SQL Server, MS Access
• Office Tools: MS Word, Excel, MS Project, MS Outlook

EXPERIENCE

Confidential

Business Analyst

• Gathering requirements in compliance with HIPAA.
• Gathering requirements through interviews and JAD sessions with business
• Working on the CA-MMIS System Replacement project consisting of the creation of the new Medicaid platform called Medi-Cal.
• Working with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements.
• Following all the phases of the Software Development Life Cycle SDLC
• Designing Activity, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate certain selection criteria and filter conditions
• Translating and transferring requirements from Business Need Document BND to Business Requirements Document BRD
• Creating Test cases and Test plans
• Contributing in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management.
• Creating test plan, test data and conducted manual testing to validate functionality and performing regression testing
• Designing Claims Inquiry screen within the MMIS and executed Testing Scenarios, Cases Conditions involving User Acceptance testing, Regression, Integration and System testing.

Confidential

Sr. Business System Analyst

• Re-engineering suite of Medicaid management products and creation of a core application called Enterprise. Worked for the team that is responsible for receiving, documenting, tracking and addressing the problems encountered by the customers of Flagship software product EPM Enterprise Practice Management while generating 837 Professional, Institutional, and Dental claims, Functional Acknowledgement 997, Claim Status Inquiry/Response 276/277 Unsolicited for their destination direct Payors or Clearinghouses such as ProxyMed, WebMD, Per Se, THIN, ViaTrack, NaviCure, McKesson, Champus-TriCare, PayerPath, ViaTrack, Access, etc.
• Involved in requirement gathering phase Provider, Claim components and HIPAA
• Utilized Rational Unified Process RUP to configure and develop process, standards and procedures.
• Met with report users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews group and one-on-one along with JAD sessions.
• Took part in the meeting held for the analysis of migration to HIPAA 5010 from 4010 and migration of ICD9 codes to ICD10
• Involved in understanding the current business process, defining scope of the project along with position statement.
• Conducted JAD sessions with management, SME, vendors, users and other stakeholders for open and pending issues.
• Involved in various meetings with business user and SME to define Business Requirements
• Processed all Medicaid claims from providers, keeps track of program expenditures, and furnishes reports that allow Medicaid administrators to monitor the pulse of the program.
• Tested billing workflow based on various financial classes such as Medicaid and Medicare
• Run electronic claims for Medicaid and Medicaid to validate the benefits and co-pay.
• Used General equivalence Mappings GEM to convert ICD 9 to ICD 10.
• Additional responsibilities included the development and implementation of standardized multi-client regulatory compliant file formats, definitions, nomenclature, policies and procedures and associated business rules pertaining to processing, literature triggers and call center scripts while adhering to HIPAA and Medicare compliance regulations .
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional requirement.
• Implemented automated COB processing of Medicare claims.
• Validated business rules and all artifacts with users, got approval and sign off.
• Tested and delivered Inbound/Outbound interfaces.
• Extensively worked with HIPAA.
• Experience with Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• Assisted Design Team in preparing SRS, Software Design Document SDD , User Interface Design, Application Architecture Database Modeling.
• Helped in project testing efforts for doing integration tests, regression tests and user acceptance tests.
• Worked on Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables.
• Made sure that the systems complied with the rules of HIPAA and CFR Part 11.

Confidential

Business System Analyst

• Worked as a Business Analyst on MMIS Medicaid Management Information System implementation for the State of Massachusetts. The system was implemented by HP formerly EDS , worked on modules or subsystems like EDI electronic Data Interface , Provider NPI and TPL Third party liability .
• Followed all the phases of the Software Development Life Cycle SDLC
• Performed Gap analysis and assessed risks of the project.
• Gathered Requirements through interviews and JAD sessions with business owners
• Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions. Worked specifically with 837, 835, 834, 270/271, 276/277
• Observed extensive troubleshooting for the failures in mapping systems for outbound claim payment transactions 835 .
• Took part in the meeting held for the analysis of migration to HIPAA 5010 from 4010 and migration of ICD9 codes to ICD10.
• Developed and tested ETL applications for the warehouse application according to functional specifications using Informatica, Unix scripts, and Oracle PL/SQL and SQL .
• Wrote complex SQL queries to extract and validate the data from s database.
• Experienced with the communication management.
• Gathered requirements in compliance with HIPAA.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements.
• Extensively worked with different X12 Hierarchical Levels HL structures in various inbound claim/inquiry-response transactions 837 P/I/D, 270/271, 276/277
• In-depth understanding of terminologies like 21 CFR Part 11, FDA, Medicaid, Medicare, HIPPA, HL-7.
• Performed System Integration and Regression Testing for the Microsoft BizTalk 2002 applications. These are developed to perform EDI translation from ANSI ASC X12 layout to MMIS Medicaid Management Information Systems fixed-width record format
• Experience in Business Process Analysis.
• Translated and transferred requirements from Business Need Document BND to Business Requirements Document BRD
• Designed Activity, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate certain selection criteria and filter conditions
• Created Test cases and Test plans
• Supervised unit testing and performed UAT testing

Confidential

Business System Analyst

• Confidential and Healthcare partnership- Confidential developed New MMIS system for centralizing the all-Healthcare related transactions all over the state. The New MMIS project is a large IT project replacing the Confidential claims payment system. Participated in all aspects of testing the New MMIS Primary responsibilities is to ensure that the system functions as designed, meets the requirements of the business community and conforms to all applicable Federal and state laws. Worked on the claims and provider modules of the New MMIS system.
• Assisted the project manager in the creation of the project charter BRD, FRD vision document during the inception phase of the project
• Performed GAP analysis as pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process
• Understood EMEVS, the NY state's electronic Medicaid eligibility verification system the Medicaid Medicare intermediary along with their roles in claim processing
• Produced Activity diagrams with defined swim lanes as part of claims process analysis
• Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming developing questionnaires
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization
• Used TriZetto HIPAA Gateway to comply with HIPAA standards 270/271, 276/277 837 for EDI transactions
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 270, 276, 278, 834, 837 I,P,D and 820 standards
• Designed Claims Inquiry screen within the MMIS and executed Testing Scenarios, Cases Conditions involving User Acceptance testing, Regression, Integration and System testing.
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management.
• Owner of the business rules document which documented the business rules across different systems.
• Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments, assist with integration and script testing, downtime activities/testing
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio
• Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan
• Created test plan, test data and conducted manual testing to validate functionality and performed regression testing
• Clarified to claims personnel the new Affinity payments and Explanation for payments EOPs for same claim processing cycle
• Designed and implemented complex SQL queries for testing and data validation using Cognos.
• Conducted user training pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity mainly occur with EOPs, capitation rosters, PCP membership rosters, provider directory listings and some system generated letters

Confidential

Business Analyst

• Confidential is a Statewide Immunization Information System. A centralized data repository used to collect and maintain immunization records of children, adolescents, adults and to collect, maintain Providers' vaccine inventory data. Users of the system include Providers Hospitals, Local Health Districts, and Clinics , Managed Care Organizations, Confidential Immunization Program Staff, ODJFS Medicaid Staff and ODH Lead Program Staff and School Nurses
• Analyzed the System Requirements, Functional requirements and Business Requirement Documents
• Developed Test Cases and Test plans for Reformat and Routing Process for the IMPACT SIIS Application in a scrum environment
• Extensive use of Quality Center for managing project documents, test cases and test reports.
• Worked closely with the developers on review and resolution of issues.
• Performed back end testing by writing SQL queries to review the returned data to ensure that the correct data was retrieved
• Focused on HIPPA Transaction sets such as Claims Submission, Premium
• Payment to health care provider, Billing claims codes, Enrollment and disenrollment Eligibility, and Billing
• claims.
• Efforts went in accordance with EAI/EDI/HIPAA Compliance.
• Created XML to test messaging systems
• Used Microsoft Team Foundation Server to report and track bugs and generated defect summary reports.
• Tracked the defects using Quality Center and generated defect summary reports
• Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
• Created Use-Cases and Requirements documents to document business needs.
• Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts, Under Writers and other potential users of the application.
• Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
• Created and maintained the Requirements Traceability Matrix RTM . .
• Worked directly with software engineers to ensure clear communications on requirements and defect reports.
• Followed the RUP methodology for the entire SDLC.
• Used the guidelines and artifacts of the Rational Unified Process RUP to strategize the implementation of Rational Unified Process effort in different iterations and phases Inception, Elaboration, Construction and Transition of the Software Development Life Cycle.
• Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated the scripts to make sure they have been executed correctly and meets the scenario description.