SUMMARY

• Business Analyst with 7+ years of experience in Healthcare and Insurance industry.
• Extensive experience in Requirement analysis, Business Modeling, and Use Case development using UML methodology.
• Knowledge of the System Development Life Cycle (SDLC), Waterfall, Agile (Scrum) and RUP methodologies.
• Good understanding of health care industry, claims management process and Medicaid and Medicare Services
• Using Facets for various health insurance areas such as enrollment, member, Products and other FACETS related modules
• Experience in testing Facets applications and EDI transactions
• Experience working on 4010 and 5010 HIPAA implementation guides relate to Claim Testing and Medical Billing on Windows, Web and Mainframe platforms.
• Experience with Reimbursement Mythology for inpatient and outpatient
• Experience in partaking Joint Application Development (JAD) sessions.
• Processed and priced APR DRGS were linked to Mainframe Platform Systems.
• Experience in developing Use Case diagram, Class diagram, Activity diagram and Sequence
• Involved in maintaining Traceability Matrix, performing GAP analysis.
• Experience in Conducting User Acceptance Testing
• Ability to work in any environment and meet project deadline
• Experience using MS Share Point
• Ability to execute mid to advance level SQL queries, sub - queries and multiple joins.
• Knowledge of the EDI transaction sets such as 837, 834, 835, 270, 271, 276, 277
• Good Understanding in health care organization such as PPO, HMO,POS

TECHNICAL SKILLS

Methodologies: UML, RUP, Waterfall, JAD, Agile

Database: SQL, Oracle, MS Access

Requirement Tracking Tools: Rational Requisite Pro, Test Director, Quality Center

Office Tools: MS Word, Excel, PowerPoint, Outlook

Modeling Tool: Microsoft Visio, Rational Rose

PROFESSIONAL EXPERIENCE

Confidential, Shrewsbury, Massachusetts

Business System Analyst

Responsibilities:

• Followed up with the Subject Matter Experts to ensure proper mapping were done from source extract
• Used ETL Process Flow Diagram for Data Mapping of file layout
• Collaborated in Join Application Development of the Lab Test, Claims, Member, Provider, Facility Affiliation files.
• Involved in Provider reporting based on the encounter data to filter and group metrics as well as set security options for users
• Involved in estimation of data sets as well as historical data provided as part of new tool implementation
• Involved in Data Analysis for the data warehouse and data mart system for the process of report generation of the data.
• Implemented Reimbursement for the payment system with home health resource groups and monitored provider payment
• Made product adjustment for low utilization payment based on member eligibility, date of service, benefit plan and co-payment
• Identified National Provider Identifier used in representation in provider file
• Wrote requirement for primary care physician NPI used in the member file
• Estimated volume of data provided in initial implementation as well as the ongoing monthly feed.
• Worked with developers in understanding business process and data mapping logic of target tables
• Write SQL code to extract data from various systems.
• Involved in data integration of Members, Provider Types, Lab Tests, RX Claims and Medical Claims and implemented 5010 data into data processing.
• Used SQL queries to extract, do counts and retrieve the data for Data Validation and Verification
• Took part in sprint meeting and product backlog.
• Mapped ICD 9 - ICD10 data for application development
• Provided support with ICD 10 support for product deployment
• Involved in Requirement Traceability Matrix to trace back Requirements to Use Case
• Worked with Data warehouse SME to perform data validation
• Performed Gap Analysis on File Layout Specification versions

Confidential, Franklin Lakes, New Jersey

Business Analyst

Responsibilities:

• Involved in various meetings with business user and SME to define Business Worked as the communication line in between the technical groups and the business group
• Participated JAD sessions to complete the prerequisite for the Business Requirement
• Discussed, Interpreted and redefined the Business Requirement for testing effort
• Created Use Case, Sequence, Activity and Entity-Relation Diagrams to illustrate for testing effort
• Conducted Gap Analysis for the Current and future process
• Ran query to identify multiple providers from effective and term date of the prescriber at the time of service
• Wrote SQL code to extract data from various systems, scrub the test data to suit testing needs and re-process new claims in the new systems.
• Defined physician groups to represent all Providers and Specialist use for data mart to enhance performance through reduce complexity
• Performed Data Analysis for multi-carrier data feed
• Wrote requirement document for Data Extraction, Data Analysis and Loading process of collected data as a part of data mapping procedures.
• Assisted in maintaining and managing test timelines
• Tested data to check HIPPA eligible & participation check for individual coverage Investigated application bugs, reported & tracked testing process using the bug-tracking tool quality center*
• Experience with Membership/Subscribers, claims processing and Billing modules mainly for the claims processing and data management and for the data reporting
• Maintained Test Matrix and Traceability Matrix
• Performed Gap Analysis for organization, with a focus on claims processing
• Uploaded all files into sharepoint and maintained version history
• Involved in project management weekly estimates of remaining work to do, conducting informal meetings as needed

Confidential, Dearborn, Michigan

Business Analyst

Responsibilities:

• Involve in HIPAA/EDI Medical Claims, Design and Documentation
• Monitor and Analyzed activity report and transaction monitoring
• Creating document and diagrams for membership enrollment according to HIPAA 834 compliance standard for membership enrollment
• Participated in daily scrum meeting and sprint management
• Conduct meeting with the development team to discuss any requirement changes.
• Checked inbound/outbound HIPPA regulated EDI transactions facets
• Conducting business validations, covering the following deliverables: (FACETS Providers, Facets Claims and Facets Membership and Operational reports)
• Involved in GEM (General Equivalence Mapping) tools for forward mapping of ICD 9 - ICD 10 codes
• Create documentation for current process and new ETL and data warehousing field changes
• Performed GAP analysis of business rules, business and system process*
• Worked on Data Mapping to map Facets data to outbound eligibility extracts
• Worked on solving the errors of EDI 834 load to Facets through MMIS
• Performed GAP analysis for ICD - 10 and EDI
• Designed Activity, Sequence and process flow diagrams using MS Visio to simplify and elaborate certain selection and filter condition.
• Performed EDI duties such as FTP of files to and from our Clearinghouse.
• Documented requirement using Use Case analysis Involve in testing the applications to carry out data validation

Confidential, Mars, Pennsylvania

Business Analyst

Responsibilities:

• Worked on application such FACETS, HIPAA data enquiry
• Participated a Joined Application Development (JAD) session with the sponsor, developers, and project manager
• Created work flow diagrams with MS-Visio like ER diagrams, sequence diagram, activity diagrams etc
• Monitored claims processing, charges and verified correct payment of claims.
• Wrote requirements for FACETS implementation to streamline transaction
• Worked with Billing, fee processing and Claims teams to understand and define the requirements.
• Help in preparing the training material of the providers and insurance companies using the software supporting ICD 10
• Mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards like ANSI
• Developed an implementation guide for Partners for EDI X12 transactions such as 835
• System-Integration and User Acceptance Testing and Validation of Medicaid claims processing and Electronic Data Interchange (EDI) translation in compliance with the 4010A and 5010A
• Performed GAP analysis for ICD - 10 and EDI Message Structure with the 4010 Structure.

Confidential, Sterling, VA

Jr. Business Analyst- Intern

Responsibilities:

• Gathered user requirements and created use case model
• Facilitated many JAD Sessions.
• Used Requisite Pro for activities such as requirements definition and organization.
• Followed up with the SME in every module to ensure that HIPAA guidelines are being followed.
• Tested user interface and navigation controls for the application using by the QTP.
• Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets
• Tested data to check HIPAA- eligible & participation check for individual coverage.
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions
• Involved in preparing use cases and business flow diagrams for the applications using UML.
• Traced requirements to high level design, test cases and product requirements.
• Created High level and detail process flow diagrams in form of Swim lane diagrams to depict the Business requirements.
• Extracted data and analyze based on the user requirements.
• Worked with project manager and other users and created work flow diagrams using MS Visio/UML.
• Co-authored change management control plan, Created risk analysis documents and created risk management plan.

Confidential, Cambridge, Massachusetts

Clinical Consultant

Responsibilities:

• Consistently hit or exceeded monthly sales quotas in three separate product categories
• Successfully communicate with expecting families and medical professional nationwide, educating them on the current and future benefits of preserving cord blood.
• Develop strategies unique to various socio-economic situations that were necessary and effective in order to position Confidential as an industry leader
• Work as a team player to assist new hires and teammates who were struggling to hit their numbers in specific product categories and promote a positive work environment

Confidential, Washington DC

Intern

Responsibilities:

• Advised Confidential on foreign policy issues particularly on US-India nuclear deal.
• Answered constituent written and telephone correspondence, and Attended Congressional meeting and hearings.
• Researched political issues for legislative staff particularly foreign aid and spending.