SUMMARY:

• Experienced Business Analyst with Over 6 years of professional knowledge in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, migration, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Documented Non - functional requirement documents, Business Requirement Document (BRD) and Functional Requirement Document (FRD).
• Functional knowledge in developing and implementing Claim Processing Systems.
• Expertise in performing GAP analysis and Impact analysis driving internal and external requirements.
• Interacted with the Stakeholders, End Users to understand and gather stakeholder requirements and create the Business Requirements Document (BRD) and Functional Requirement Document (FRD) and communicating it to the entire team involved
• Comprehensive experience in different SDLC methodologies: Waterfall, Agile and Rational Unified Process.
• Test case writing (manual/automated) and conducting different tests; Integration and regression testing, UAT (User Acceptance Testing).
• Knowledge of Analysis & Design (Use Case, Sequence and Activity diagrams) using Unified Modeling Language.
• Writing Manuals (System guides, material for business users and Deployment guides).
• Good knowledge in RDBMS, Oracle, SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• User on the changes being released and conducting post production activities like getting feedback from users.
• Good understanding of EDI Transactions 270/271, 278, 837I, 837P, 835, 834, 820, 276/277.
• Strong understanding of FACETS and Facets Data Model working on data model and data extracts.
• Experienced working in Facets online modules such as Billing, Provider, Claims and modules.
• Strong experience in documenting existing process, analyzing business requirements, working with requirements traceability matrix, re-engineering business processes and designing.

TECHNICAL SKILLS:

Methodologies: Waterfall Methodology, Agile Methodology, RUP (Rational Unified Process)

Version Control: Rational Clear case, Visual Source Safe

Change Management: Rational Requisite Pro, Clear Quest, Test Director.

Testing Tools: Rational Enterprise Suite, Test director, Win Runner

RDBMS and Databases: MS Access, SQL server, Oracle 9i, Sybase

Languages: C, C++, Java, JavaScript, NET, XML, XHTML, UML, SQL, HTML

Operating Systems: Windows Family, Familiar with UNIX and LINUX

Office Tools: MS Office, Word, Excel, PowerPoint, Visio, Outlook.

Project Management: Microsoft Project, Microsoft Office

Reporting tools: Business Objects

PROFESSIONAL EXPERIENCE:

Confidential, MI

Business Analyst

Environment: FACETS 5.01, EDI 837, 835, 834, MS SharePoint, Oracle SQL Developer (3.1.07), Microsoft Office, PowerPoint, Visio, MS Access, Quality Center

Responsibilities:

• Preparing Business and functional requirement documents to access all the requirements for the successful implementation of HCR.
• Used Agile methodology to develop process and standards.
• Conducted JAD sessions with various SMEs and users to analyze and discuss project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Support the Business Configuration Team (BCT) for creation of FACETS Group, Subgroup and class for Individual HMO On/ Off Exchange and Individual PPO On/Off Exchange for HCR in Facets Front end.
• Document APTC Configuration Process including Exchange Rules, Delinquency Definition and APTC Eligible Indicator.
• Setting up Fee Definition and Fee Calculation in FACETS for QHP Individuals, Grandfathered/ Transitional Small Group, QHP Small Group and Large Groups
• Conduct the Walkthrough meeting with Business user to illustrate HCR Group Structure, HCR Plan and Product, HCR APTC Billing Group.
• Created UML diagrams including Use Case Diagrams, Activity Diagrams, and Sequence Diagrams using Microsoft Visio.
• Developed data mapping documents and Functional Design Document to support the data extracts to be supplied to Delta Dental for identification of Dental Members.
• Developed data mapping documents to support the data extracts to be supplied to Functional Design Document.
• Performed data analysis and created data mapping and data analysis document.
• Prepare the functional design document for Delinquency and Provider Letter.
• Developed test scripts and test cases to test the eligibility as well as provider side of the delinquency implementation.
• Worked on developing the business requirements and use cases for FACETS batch processes; automating the billing entity and commission process

Confidential, Virginia Beach, VA

Facets Business Analyst

Environment: FACETS 4.71/ 5.01, HIPAA 4010/5010, EDI 837, 270, 271, Quality Center, JIRA, MS Visio, Word, Excel, PowerPoint, SQL, .NET.

Responsibilities:

• Gather the requirements from the Business Owner & SME.
• Document the requirements categorized into Regulatory & Operational in the Business Requirement Document (BRD).
• Facilitate numerous meetings for the creation of design documents, gathering requirements from the users, Business Owners & Project Managers.
• Analyzed on Facets 4.7 & Facets 5.0 Versions.
• Create and communicated the prototype requirements to the development team in Excel formats as templates for the reports.
• Assign tasks to the project development team, monitoring and tracking process of the project.
• Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler.
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (, Billing, Provider)
• Responsible for maintaining the change notification request document and communicating with the developers in each iteration & review meetings.
• Create and managed requirement types and traceability relationships.
• Apply knowledge & experience of HIPAA Act Rules and Regulations & HIPAA transactions.
• Perform research on Member, Provider, Claims, Authorization, Appeals and Grievances data from Facets back end and front end application system for reporting purposes.
• Extensiveinvolvementin data mapping using Facets data model.
• Acquire signoffs at the beginning and end of each process from the project sponsors.
• Accountable for creating Test Plans and conducting the testing and defect analysis.
• Perform ICD10 impact analysis on all corporate extracts and letters generated by Amerigroup for all markets.
• Perform unit testing of /271 Eligibility transactions with one of Amerigroup vendor Emdeon.
• Extensive use of Facets back end tables and front end application system for data validation purposes.
• Perform UAT with the Business Owners respectively.

Confidential

Facets Business Analyst

Environment: HIPAA 4010/5010, FACETS 4.71, EDI 837, 835, 834, ICD 9 CM & ICD 10 CM, MS Visio, Word, Excel, PowerPoint, SQL.

Responsibilities:

• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Ensured all artifacts compiled with HIPAA 5010 policies and guidelines.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Gathering requirements and preparing functional documents for Facets 4.71.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Created workflow diagrams, UML diagrams, activity diagrams, use cases.
• Performed the detail comparison between 4010A and 5010 to identify differences across loop structures.
• Did gap analysis for HIPAA P and 835 transactions and HIPAA P and 835 transactions.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems as well as for ICD 9 to ICD 10.
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEMs and incorporated that into a Translator Tool.
• Designed and supported in Test cases, Test plan creation and Companion Guide from development stage to production, including both internal and external requirements.
• Conducted Business Requirements walkthrough with the business owners as well as the Technical Stakeholders.
• Participated in the monthly steering committee meetings to update the Business Sponsors on the project schedule and financials.
• Helped in the development and rollout of the ICD 10 and Curriculum Development Plan.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Established Traceability Matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.

Confidential, New York, NY

Business Analyst

Environment: FACETS 4.51, Agile, SQL SERVER 2008, ANSI X 12 10, EDI 837 I and 837 P, MS Visio, MS Project, Microsoft PowerPoint, Rational Requisite Pro, Rational Rose, QTP.

Responsibilities:

• Extracted theBusinessRequirementsfrom the Business Users and documented it for the developers following theHIPAA guidelines by conductingJADsessions and Interviews.
• Initiated with a comparison report of migration of . 270 Eligibility, coverage and benefit inquiry (V4010X092A1) Vs. 270 (V5010X279).
• Worked on different modules of Facets such as Members/subscriber, commissions, provider, billing and plan.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270, 271, 276, 277, 834, 835 and 837, to meet HIPAA requirements set forth by the federal government.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process.
• Worked on requirements of the 835, 276, 277, 837, and HIPAA transaction across the enterprise.
• Met with the Provider and Trading Partners to ensure that HIPAA transactions pass the EDI gateway and interpret technical difficulties into simple language.
• Designed a high level spec document to show various paths that need to be taken into consideration for the transformation phase of .
• Involved in Service Oriented Architecture (SOA) of the claims processing system.
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Troubleshoot any problems found within FACETS and when testing the SQL data database while validating the business rule.

Confidential, Cypress, CA

Business Analyst

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, Rational Requisite Pro, MS Office, SQL Server, Agile, MS Project, MS FrontPage 2003, MS Access, EDI, UML.

Responsibilities:

• Performed the Requirement Analysis, Impact Analysis and documented the requirements using Rational Requisite Pro.
• Responsible for data mapping of HL7 messages into relational database.
• Conducted Gap Analysis to check the compatibility of the existing system infrastructure with the new Business Requirements.
• Built Business Requirement into the Medicare Advantage (MA) requirements database and created the project Requirements document for three functional areas.
• Reviewed the Joint Requirement Documents (JRD) with the cross functional team to analyze the High Level Requirements.
• Responsible forPrior Authorizationand dealing with Managed Care and monitored customer flow data.
• Been a part of Architecture and modeling team and have used SOA (Service Oriented Architecture).
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.
• Worked on billing system a cash management module and enhanced the encrypting standards that are required for the application.
• Interacted with client and the technical team for requirement gathering and translation of Business Requirements to Technical specifications.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Planned and documented procedures for data processing and prepared data flow diagrams for the application.
• Designed workflows and allocated permissions within SharePoint.
• Documented the Traceability Matrix for tracing the Test Cases and requirements related to them.