SUMMARY

• Over 8years of experience in Information Technology Consulting developing projects in different SDLC methodologies like Agile SCRUM , RUP, Lean-IT, Iterative and Waterfall models.
• Strong Business/System Analytical Analysis Skills including in depth knowledge of Software Development Life Cycle SDLC , having thorough understanding of various phases like Requirements, Analysis/Design, Development, Testing and Implementation.
• Excellent business writing skills in writing Preliminary Investigation Report, Business Requirements document, Systems Requirements/Design Specification, Functional design documents and System Requirement Change Request.
• Experienced in conducting Gap Analysis sessions for As-is and To-be systems and mapping present as well as future state business flows/processes.
• Hands on experience in generating reports and conducting analysis to identified any potential issues as well as areas of improvement.
• Experienced in hosting Joint Application Development JAD sessions with end-users, internal/external vendors, SMEs, developers and architects.
• Proficient at transforming business requirements into functional/technical requirements and designing business as well as architecture models using Rational Requisite Pro and MS Visio.
• Experienced in outsourced projects having worked as Team Lead on onsite-offshore model
• Expert in analyzing/designing/re-engineering complex systems internal to the enterprise and also to integrate with several external systems on different platforms/architectures.
• Expert in Root Cause Analysis, Feasibility studies and Risk Assessment studies.
• Extensive Knowledge of Systems Management, Design and Domain Driven Data Modeling.
• Experienced in Functional, Regression, Integration and User Acceptance testing with development, execution and maintenance of test plans, test cases, test scenarios and metrics.
• Experienced in documentation defined as per Sarbanes Oxley SOX compliance.
• Skilled at handling multiple projects simultaneously supported by strong communication and management skills.
• Extensive knowledge of Health Care and Pharmacy domains HIPAA mandates, EDI, ANSI 837/835 4010 and 5010 versions, ITS, Claims Processing, Accumulators, Product, Provider, Eligibility, NCPDP formats, Formulary files and Drug databases.
• Expert in Trizetto Health Care Management System Facets
• Extensive knowledge in MZI's EZNET, EZCAP Claims Processing System.
• Experience with Medicare, Medicaid and commercial insurances in HIPAA ANSI X12 formats including 270/271,276/277,820, 835, 837, 997/999
• Trained resources on-board by devising appropriate training and support documentation.
• Demonstrated high capacity to learn new technologies rapidly with no formal training.

TECHNICAL SKILLS

Operating Systems: MS-DOS, Windows 2000/2003/NT/95/98/XP/ME, UNIX

Languages: C, C , Java, XML, SQL, PL-SQL, UML.

Testing Tools: Rational Test Manager, Rational Quality Manager

Business Process Management: PEGA CPMHC, Rational Requisite Pro, MS-Visio,

Defect Tracking Tools: Test Director, Quality Center, Clear Quest.

Utilities: MS-Office Suite, MS-Project, Ultra Edit, SOAP UI

Databases: SQL Server 2000, DB2, Sybase, MS-Access, Oracle

Configuration Management: Clear Case, Share Point Portal, Lotus Notes

Methodologies: SCRUM, RUP, UML, SDLC, JAD, RAD,

Reporting tools: Brio-Hyperion

Query tools: Advanced Query Tool AQT , Sybase Advantage, Microsoft Visual Studio.

Data transfer protocols: MQ series, SBI, CBI, FTP, SFTP, SOAP Web Services

DOMAIN KNOWLEDGE

Confidential , EDI, Claims adjudication and processing, Pricing, Claim Validation Routines, Utilization Management, EOB, Remits, Provider, Group, Member, Billing, Accumulators, CDHP HAS/HRA/FSA , HIPAA 4010/5010, Individual/Group/ASO/National/State Sponsored/Medicare Business, ITS,CMS 1500, UB04, Pharmacy Prior Authorizations, Formulary files, NCPDP file formats.

PROFESSIONAL EXPERIENCE

Confidential

Commonwealth Medicine is dedicated to improving health care for people in need, while also controlling costs and maximizing revenue for clients. Public- and private-sector organizations save millions of dollars annually by working with MassHealth. CHFS received Federal and private research grants and contracts exceeding 240 million in the fiscal year of 2013

Role:Sr. Business Analyst

Duties performed:

• Collect, document and analyze business and user requirements to translate into user stories, functional specifications, wireframes, system requirements, business process flows and issues for use in complex system development.
• Created business prototypes using Balsamiq Mockups
• Initiated SQL queries for production data analysis on payment generation for eligible SSP recipients.
• Provided strategic, forward-looking vision when designing solutions to maintain flexibility and future integration opportunities.
• Acted as an intermediary between business managers and users to technology teams.
• Defined the scope of activities required to address issues, including requirements definition, process review, impact assessment and operational streamlining.
• Worked on automation of daily ETL process through analysis of database stored procedures.
• Delivered training to end users.
• Acted as front line support for live solutions.

Duties performed:

• Conducted an in-depth Six Sigma analysis of ICD-10 diagnosis codes to prioritize based on frequency of occurrence for migration.
• Worked closely with the Claims Analyst on ICD-10 conversion
• Represented SSP in meetings with DTA to discuss the approach and upgrades needed for SSP application to support ICD10transformation.
• Produced Gap Analysis documents for ICD-9 to ICD 10 conversion.
• Provided current architecture of SSP system prepared in MS-Visio.

Environment: SQL Server Management Studio, MS Visio, SSP Administration System, SSRS Reporting tool, JIRAA, Microsoft Team Foundation Server, Balsamiq Mockups

Confidential

Confidential provides industry-leading management consulting and technology to help public sector education, health, human services, and other government clients achieve their performance goals and better serve populations in need. Established in 1986 with headquarters in Boston, the firm has extensive experience in all 50 states, clients in six Canadian provinces, and a growing practice in the European Union.

Role:Sr. Business Analyst

Confidential

Project focuses on adding enhancements to increase system capabilities and response to its user, also to rule out the bugs, errors, and system glitches for improvement.

Duties performed:

• Created and maintained system documentation supporting all application patches and upgrades created test cases and was responsible for performing full cycle testing.
• Maintained system protocols by writing and updating procedures.
• Initiated claim scrubbing process by running various validation routines to determine whether the claim is payable or not.
• Providedreference material for end-users by writing and maintaining documentation.
• Providedsupport in production environment and training to all users.
• Reported all system issues bugs by clear documentation
• Perform, track and support all non-technical system configurations such as setting up new user profiles, mapping EDI segments, creating provider profiles, and creation of user roles based on new programs.
• Kept a track of project progress by identifying project milestones and resolving problems.
• Performeddata analysis and documentation through various mechanisms such as claims system, queries and review of the system
• Identified potential areas of automation, and reengineered the underlying business processes.
• Determined operational objectives by business functions gathering information evaluating output requirements analyzing requirements constructing workflow charts and diagrams studying system capabilities writing specifications.
• Served as a liaison for IT Manager s , development staff, and the project stakeholders.
• Elicited business knowledge such as process flows, business rules and algorithms from knowledge workers.
• Created BRD's Business Requirement Document and FRD's Functional Requirement Document
• Initiated SQL queries to perform various DDL and DML operations on Oracle database.
• Created user stories, Flow diagrams, Screen mockups and Performance metrics.
• Quality Analysis on production data using SQL to find data discrepancies.

Environment: SQL Server Management Studio, MS Visio, MZI's EZNET, EZCAP for Claims Processing, Administration Utility and Webstrat for Claims Pricing, MS Office Suite.

Confidential

Confidential is a Fortune 500 company serving approximately 2 million members in 12 states. Amerigroup's only business is managing publicly funded health programs Medicare, Medicaid, CHIP, TANF for Nation's most vulnerable. Nationwide, they serve one out of every 35 Medicaid recipients and one out of every 25 kids covered by CHIP

Role: Business Analyst

Confidential

is developed to meet the future requirements of Amerigroup's rapidly growing business and to meet guidelines set forth by several state vs federal authorities. The new process/system also optimized business processes and effective Customer Relation Management by encapsulating work done on different systems/vendors into a single system. The new re-engineered application enabled efficient and quick turnaround of prior authorization decisions with increased real-time capabilities. PEGA Business Rules Engine is used as platform for this application for effective Business Process Management.

Duties performed:

• Performed detailed analysis of current state application by conducting Discovery sessions with CSRs Customer Service Representatives , Pharmacists and Medical Directors Documented Current State Business Model/flows using MS Visio.
• Extensive Data analysis is performed as part of identifying problem areas and areas of optimization within current business process.
• Mapped complex future state business processes with resolutions for problems identified in current state, researching future trends across industry and identifying gaps GAP Analysis from several state pre-requisites. Used MS Visio and PDF generator
• Assisted in Business Proposal document, Project planning, Resource management and ROI determination to handle changing business needs Used MS Project Plan, Excel and PowerPoint.
• Resource Management - Outlined the Resource requirements and interviewed potential candidates by working with external vendors.
• As a lead BA, assisted in Project Planning by constantly providing estimates, determining order of sprints and conducting impact analysis to timelines during scope change due to agile nature of project
• Documented Business Requirements, which encompass Purpose of the project, Scope, Business Requirements with Priority Must haves and Wish list , Risks/Assumptions.
• Conducted Story board telling sessions with multiple business partners across various departments and generated complex Use Cases with several alternate flows.
• Used Business Process Management techniques to come up with a system that is more streamlined and can be easily configurable by business with minimum effort and IT support.
• Involved in discussions with Lead System Architects across different internal vs external vendors while integrating different applications onto a single platform with real-time capabilities for quick turn around and greater efficiency.
• Hosted iterative JAD sessions with System Architect, Developers and appropriate business representatives throughout the application development process for continuous feedback to ensure that the product is being developed as per Business needs.
• Created technical mapping documents depicting the data transformations from various applications using SOAPweb services.
• Automated the prior authorization loads into Claims systems through batch file processing.
• Designed system to meet the CMS mandated TATs Turn Around Time and SLA regulations.
• Developed/Customized PEGA CPMHC framework to meet the customer needs and business process.
• Automated Drug Search/Selection by designing 'Connect SQL' between PEGA and Medispan databases.
• Analyzed huge volumes of data in Formulary files received from external vendor in NCPDP format and designed business rules in PEGA to handle prior authorizations based on formulary files.
• Designed and assisted development in building a very complex and dynamic Clinical rules engine, which determines if the member has met all the clinical criteria for the drug requested.
• Designed User Interfaces sections, data property rules, decision tables, screen flows, flow actions, Workbaskets and Workbaskets in PEGA as per customer requirements.
• Reported Status and Conducted several Demos to the Project Sponsors in a timely fashion.
• Documented Help Desk Procedures and Training material.

Environment: Facets 4.71, MS Visio, MS Office, Microsoft Visual Studio, Oracle, SOAP UI, PEGA 6.1SP2, CPMHC framework, Mercury Quality Center

Confidential

is the nation's leading health benefits company serving the needs of approximately 34 million medical members nationwide. The Central Region of WellPoint uses Facets, an enterprise-wide software solution for health care administration.

Role: Business System Analyst/Team Lead

As a Business System Analyst, I was involved in all phases of SDLC and responsible for implementation of business needs for several projects by assessing systems and eliciting business/functional as well as high level technical requirements.

Project1:

Confidential - Department of Health and Human Services HHS mandated upgrade of HealthCare Electronic X12 Transactions from HIPAA 4010 version to HIPAA 5010 version. I was involved in upgrading system for 837 transaction using Lean IT methodology.

Duties performed:

• Performed detailed Gap Analysis with EDI, End users, Down-stream systemsto analyze the impact of changed/new/deleted loops and segments on incoming claim in 5010 format.
• Partnered with Trizetto owner of Facets application and analyzed the features/technical modifications provided with Facets 4.71 upgrade for 5010 acceptance.
• Provided technical/functional/data/hardware/software and licensing requirements to satisfy business requirements.
• Re-engineered provider scrubbing process in line with changed loops/segments maintaining 98 first pass rate.
• Created complex data mappings to convert EDI 837 5010 claim into Facets XC format through Mercator.
• Created functionality and data flow diagrams to illustrate the provider scrubbing and claims inbound flow using MS-Visio.
• Re-Designed/Modified entire inbound job to process both 4010 and 5010 claims simultaneously.
• Involved in designing an up/down conversion tool which converts 837 claim from 5010 to 4010 format as part of risk mitigation/back-up plan.
• Worked with EDI and other external vendors on data locations and network connections to receive/send claim in 5010 format.
• Performed data scans and sandbox testing to analyze the impact of data changes and proposed design models on end-end clams flow.
• Involved in creating project plan by providing LOEs at different gates.
• Represented Central Facets in several meeting with EDI, CMS Medicare and other external systems to come up with 837 edits acceptable to every system.
• Created new data fields and tables to house loops and segments, which are not required for claims processing, but have to be sent out on 835/837 outbound to be 5010 compliant.
• Conducted JAD sessions with development/architect team and proposed models to accept clam in both 4010/5010 formats with no significant impact to batch processing time.
• Played a vital role in resolving technical/timing/implementation issues with other projects by designing an approach feasible to everyone.
• Managed and lead a team of 6 offshore analysts.

Project2:

Confidential Designed system to be in compliant with different prompt pay laws for each state IN, KY, OH, MO, and WI , which require an interest to be paid on claim if not processed in a pre-defined time frame. Involved in major audits and implementing significant state prompt pay mandates including MCS Shane discontinue.

Duties Performed:

• Conducted As-Is and To-be Gap Analysis sessions to understand the current state of business/system for existing prompt pay laws and impact due to new laws.
• Partnered with business and legal teams to elicit prompt pay business requirements for each state.
• Modified functional design documents by updating logical/data flow to ensure system is in compliant with new prompt pay laws.
• Trained development, testing and other business system analysts with new prompt pay laws to ensure all other projects are in compliant.
• Assisted development team in understanding the complex logic involved in each state law by providing state and logic flow diagrams created on MS-Visio.
• Designed complex reports for each state which gives the amount of interest paid by claim type, business, type of interest, provider type and various other factors as mandated by state departments.
• Executed complex database queries and submitted analysis reports during audits.

Other Projects in WellPoint:

• Sybase Upgrade Upgraded database from Sybase 12.5 to Sybase 15. Involved in analyzing the system due to changes in indexes and designed system to ensure the functionality/stability is not disturbed due to database upgrade.
• Facets upgrade Upgraded Trizetto Facets application from 4.11 to 4.41. Modified functional design documents to integrate with the new Facets version while safeguarding the existing business and functionality. Involved in testing all the batch jobs ERCMCRUNXC00, ERCMCRUNCLMU, ERCMCRUNCKMM, CLPO and BILO .
• NPI Modified provider scrubbing logic to include NPI as the primary identifier for provider.

Environment: Facets 4.11/4.41/4.71, Sybase 12.5/15, AQT Advance Query Tool , Sybase Advantage, Ultra Edit, Unix, Ultra Edit, Rational Requisite Pro, Rational Clear Quest, Rational Clear Case, Rational Quality Manager, MS office, MS-Visio, Brio-Hyperion, SQL, Java, SharePoint, Lotus Notes, Windows 2000 sever/XP.Confidential is a major health care management company in Indianapolis catering to insurance needs of individuals, small/medium/large employee groups, Medicare, Medicaid and many other state/federal programs.

Role: Business System Analyst

As a Business System Analyst, I was involved in all phases of SDLC and responsible for implementation of business needs for several projects by assessing systems and eliciting business/functional as well as high level technical requirements.

Project 1:

Confidential

to pay predefined deductible to avail his/her HRA benefits. A new module is purchased from Trizetto for this implementation.

Duties performed:

• Performed sandbox testing of a new HRA module from Trizetto to understand the functionality, technical configurations, and business/functional integration with existing process.
• Involved in documenting the functionality, configuration and step by step business/data flow of new DHRA module.
• Transformed business requirements into functional/technical/licensing and data requirements.
• Hosted several meetings with Lumenos to gather requirements on the file formats to be used for receiving/sending accumulators.
• Documented functional designs which include database tables to be created/modified/used, functional/data flow diagrams, data mappings, step-by-step logical flow to meet business requirements systematically.
• Conducted training sessions on the new module for developers, testers and other project teams.
• Provided LOEs at different confidence levels for each gate of implementation.
• Collaborated with architecture team in re-designing the existing system to integrate the new HRA module.
• Involved in discussions for test approach, test data needs and provided suggestions during test plan reviews.
• Assisted end-users in creating data models in business objects for report generation.
• Managed a team of 4 offshore analysts.

Project 2:

Confidential

Duties Performed:

• Conducted JAD and review sessions with external vendors to gather requirements and to agree on a business flow feasible to both systems.
• Involved in documenting Service Level Agreements for file transfers and procedures to follow in case of any delays/failures.
• Documented technical requirements and functional design documents eliciting data and logic flow.
• Created Data Mapping documents and inbound as well as outbound file formats.
• Worked with Development SMEs to determine the file transfer methodologies and batch integration.
• Involved in end-end UAT testing to ensure the accumulators are posted accurately by processing a huge variety of claims.
• Involved in production check-out and validations by executing queries and reviewing reports.
• Prepared documentation and got approvals as required by Sarbanes-Oxley act.

Environment: Facets 4.11/4.41/4.71, Sybase 12.5/15, AQT Advance Query Tool , Sybase Advantage, Ultra Edit, Unix, Ultra Edit, Rational Requisite Pro, Rational Clear Quest, Rational Clear Case, Rational Quality Manager, MS office, MS-Visio, Brio-Hyperion, SQL, Java, SharePoint, Lotus Notes, Windows 2000 sever/XP.

Confidential

Development of a new Health Information System using the COTS product for managing cases for all public health programs offered. It handles billing of commercial other insurance claims using HIPAA transactions.

Role: Systems/QA Analyst

Responsibilities:

• Gathered business requirements using structured interviews, workshops and brainstorming
• Analyzed client's business requirements and designed use cases
• Documented Software Requirements Specifications
• Coordinated creation of end user documents such as User and Configuration guides
• Aided JAD session follow-ups for project plan updates and gained consensus for User Acceptance Testing requirements
• Worked with UAT team to validate the developed application meets the business requirements
• Conducted daily status meeting with development team, deployment team, and business during UAT to resolve outstanding issues and assign priority and severity to defects.
• Worked with the Quality Assurance Team to test different releases and to develop test plans and test cases.
• Performed Data-driven testing by inserting multiple sets of data into the application.
• Compiled Test Scripts and generated reports for identified errors in the application using Test Director 7.6.
• Prepared SQL scripts to verify the database updates, inserts and deletes of the records in Oracle database.
• Provided User Acceptance Testing support by feeding data and running scripts.

Environment:Windows 2000, SQL Server, VB.net, Mercury Test Director, SQL, and MS Office Suite for documentation