SUMMARY

• Over (7+) years of experience as a Business Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services and insurance sector
• 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.
• Experienced with ITIL process workflow Incident management, Change management and Problem management
• Knowledge of the EDI transaction sets such as 837, 834, 835, 270, 271, 276, 277, 999
• Understanding of HIPAA Standards and Compliance issues, HIPAA Privacy policy, opt in/opt out policy.
• Extensive experience with Object oriented Analysis and Design using Rational Unified Process (RUP), Waterfall methodology and Agile Modeling
• Requirements gathering in compliance with HIPAA 4010 and 5010 standard.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document (BRD) and Functional Requirement Specifications (FRS) document.
• Excellent understanding and hands on experience with HL7 Messaging Standards, HL7 Message Validation, HIPAA and EDI transactions. Knowledge of Electronic Medical Record (EMR), Electronic Health Record (EHR) and Facets.
• Experience in creating SQL queries to facilitate UAT and perform data validation.
• Designed High level design, for New process, integrating with legacy and Facets
• Facilitating one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
• Experience in creating SQL queries to facilitate UAT and perform data validation.
• Experience in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility,
• Good knowledge and extensively worked in healthcare insurance domain including Medicare, Medicaid and commercial Insurance. Proven experience with HIPPA ANSI X12 EDI transaction codes such as 270/271(inquire/responsehealthcare benefits), 276/277, 810, 834(Benefit enrollment) 835(Payment/remittance advice), 837I (Healthcare claim) and 837P, 997.
• Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Experience in Health Care Industry with exposure to Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems.
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835 /271 transactions.
• Proficient in conducting System Testing, Functionality Testing, Regression Testing, User Acceptance Testing (UAT) and training of users
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules ofFacets.

TECHNICAL SKILLS

Process/Modeling Tools: Business Process Analysis & Design, Requirement Gathering, Use Case Modeling, JAD/JRP Sessions, Gap Analysis, and Impact Analysis.

Testing Tools: Rational Enterprise Suite, Test Director. Load Runner, QTP, Quality Center

Operating Systems: UNIX, Windows, Linux, and MS - DOS

Reporting Tools: Quality Center, Rational Clear Quest

Methodologies: Agile, JAD, Waterfall, RUP, RUP, SDLC, Agile, Methodology, JAD

RDBMS: SQL, Oracle, and MS Access, MS SQL server, MS Access, IBM DB2

Utilities/Application: MS Project, MS Visual, MS Office (MS-Word, MS-PowerPoint, MS-Excel, MS-Access, MS-Outlook)

PROFESSIONAL EXPERIENCE

Confidential, Chicago, IL

Business/Facets Analyst

Responsibilities:

• Authored Test cases for HIPAA EDI Transactions 270/271, 276/277,837/835.
• Tested HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Gained strong understanding of Eligibility & Enrollment, Consumer driven products (CDP/CCF initiative) such as HSA, HRA, FSA and tradition HMO/PPO products & associated systems
• Worked on 4010 HIPAA Electronic Data Interchange (EDI)Transactions, HIPAA X12, 837 medical claims, 835 Electronic remittances 270/271Elegibility inquiry and response, NCPDP, NCPDP Batch Transaction Set, ICD 9 Codes, National Provider Identifier (NPI), HCidea.
• Troubleshoot any problems found within FACETS and when testing the SQL data database while validating the business rule.
• Developed comparative statements, reports to examine the existing functionalities and presented to the Board of Directors. Also created Business Process Workflow Diagrams.
• Provided the solution to enhance the existing functionalities and segregated Business Requirements into high level and low level Use Cases.
• Documented detailed Business Requirements Documents (BRD) and Functional Requirement Documents (FRD) using Rational Requisite Pro.
• Approve and deny FSA and HRA claims for participants by reviewing documentation submitted for reimbursement
• Created UML diagrams with the help of Rational Rose to understand the process flow.
• Conducted JAD sessions periodically in order to resolve any issues in requirements and providing the data to the external vendor.
• Checked inbound/outbound HIPPA regulated EDI transactions facets
• Followed a structured approach to organize requirements into logical groupings and ensured that the critical requirements are met.
• Participated in ICD 9 to ICD 10 codes mapping sessions as well as status meetings and provided comments and suggestions on challenges faced with the outsourced medical coding partner company.
• Identified the business flows and determined whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Developed complex queries in T-SQL, wrote Stored Procedures, Triggers and Queries with best execution plan. Created cubes and dimensions for the analysis of sales in specific areas.
• Used Electronic Data Interchange (EDI) codes for verifying patient eligibility and receiving the insurance benefits, patient information, healthcare claims processing request, and healthcare claims submissions through the new EMR System.
• Conduct employee HRAs/needs assessment/employee surveys: review medical/script/disability claims x 3 years, employee absences, EAP use; in corporate employee demographics/interests
• Sourced procedure codes and medications from the data store of FACETS claims.
• Made sure the agency is in compliance with Medicare regulations about the OASIS collection and transmission/export of patient files to CMS, as per the mandate.
• Coordinated periodic meetings between the user group and KINNSER at various phases of software installation and training phase.
• Used Rational Clear Case to track and fix bugs.
• Participated in coordinated team effort in User Acceptance Testing (UAT).
• Actively involved in the training of end users of all levels. Conducted training sessions for the staff and vendor companies.

Environment: EDI X12N 4010, FACETS Agile Methodology, MS SQL Server UML, Ms-Visio,HRA, SAS Meditech,,Nextgen.Clear Case, Clear Quest, UAT, JAD, UML Diagrams, MS Visio

Confidential, Middletown, NY

Business Analyst

Responsibilities:

• Coordinated with Business Owners, Application Vendor, Payers and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements
• Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, Medical policy waves
• Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD 10 such as EDI Claims Intake, Claims Adjudication, Medical Management- Utilization Management, Case management and Provider Reimbursement- Provider Payment
• Maintained and enhanced Next Gen Electronic Medical Records (EMR), Electronic Practice Management (EPM), and Imaging Control System (ICS) software.
• Organized impacted systems into high, medium and low impact to help business analyze the level of effort for remediation activities and ease resource allocation work
• Prepared use cases and data flow diagrams to analyze the impact of ICD 10 diagnosis codes, CPT and HCPCS codes embedded in different systems and applications
• Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements
• Designed and developed Billing system from the ground up.
• Implemented 837P, 835, 270, 271, 997 HIPPA documents
• Conducting business validations, covering the following deliverables FACETS Providers, Facets Claims and Facets Membership and Operational reports
• Successfully refined and implemented new and inherited projects for specialties or practices where the Next Gen KBM could not meet the client's needs or workflow.
• Performed extensive requirement analysis including Data analysis and Gap analysis.
• Designed and developed Business Rules Document about the Claim Component and HIPPA
• Developed and implemented weekly metrics management for availability management, capacity management and security management utilizing the ITIL process framework
• Designed, test, and customized EMR templates, documents and crystal reports.
• Involved in testing Facets for Group Information, Enrolling Subscribers, adding members, Related Entities, Class/Plan definition, Premium Rate Tables etc.
• Used UML for Specifications, Documentation and Construction of systems
• Used HL7 guidelines and dictionary for defining business rules associated with pre-defined workflows according to business requirements.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions
• Successfully refined and implemented new and inherited projects for specialties or practices where the Next Gen KBM could not meet the client's needs or workflow.
• Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis and expected results for 5010 compliance
• Involved in the creation of UAT test plan, UAT test scenarios and UAT test cases
• Performed backend database testing on oracle database using SQL

Environment: EDIX12N 5010, EDIX12N 4010, ICD 10 FACETS MS Project, MS SharePoint MS Access, MS SQL, EMR Prime Excel, MS Power Point, ITIL, MS Project, HP Quality Center, Agile Scrum

Confidential, Bellingham, WA

Business Analyst

Responsibilities:

• Understanding business requirements for existing and future Member and Claims process
• Analysis of the defects related to the reports and various EDI transactions within the HP system
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Utilized the ITIL-process Security Managementfor structured fitting of information security in the management organization
• Working with the application and Business Analyst team to develop requirements
• Translating process/technical solutions for business during defect analysis
• Help in preparing the training material of the providers and insurance companies using the software supporting ICD 10.
• Utilized survey assessment results of ICD-10 to create listing constraints, processes, projects and systems, applications and vendor software to be impacted by the ICD-10 Conversion Project.
• Utilized the ITIL-process Security Managementfor structured fitting of information security in the management organization
• Executed SQL queries to perform data analysis in order to generate reports, analyse data feeds from external sources.
• 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.
• Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Considered HIPAA rules while data validation and testing
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields withFACETSbatch jobs and reports.
• Healthcare system implementation including enterprise Electronic Medical Records (EMR) software.
• Participate in the scrum meeting and also represented the team during the meeting
• Working through the phases of SDLC using the Agile methodology
• Authored progress and completion reports which were then submitted to project management on a weekly basis in MS project.
• Utilized the ITIL Incident Management & Problem Management processes to integrate enterprise-class help desk portal to raise service levels and proactively solve operational challenges
• Used SQL to query the database for performing data analysis and data modeling usingErwin.
• Worked on different modules ofFacetssuch as Members/subscriber, commissions, provider, billing, plan and Case management.
• Worked on defect related to EDI 837, 835, 277 and 999 transactions
• Worked on new requirements (Change Request) and modifications on various reports that were determined as critical by the Client.

Environment: EDI ANSI X12/HIPAA, JAD, Informatics, Toad for ITIL, DB2 Oracle Version, SQL Developer, Agile, Waterfall,, MS Office tools, Facets, HP Quality Center, Windows, SharePoint, MS Visio.

Confidential, Fargo, ND

Business Analyst/ System Analyst

Responsibilities:

• Involved in gathering requirements as per the consensus meetings between Humana and providers.
• Created domain models and made them an integral part of multiple FRDs that I created for various aspects of the project.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)
• Developed Use Case diagrams and process flow diagrams using Rational Rose and MS Visio.
• Actively prioritized and managed requirements throughout SDLC with all key stakeholders
• Implemented the ITILapplication management tool to improve the overall quality of IT software development and support through the life-cycle of software development projects, with particular attention to gathering and defining requirements to meet business objectives.
• Did data analysis for various version changes of EDI messages on different sub-systems.
• Created Test Plan, Test cases and test scripts for implementation of test cases in Quality Center
• Provide input to estimates for project management and change management activities through analysis of requirements effort, resources, and technology.
• Worked on EDI 834, 835,837 as per HIPPA guidelines.
• Performed the detail comparison between 4010A and 5010 especially in regard to EDI 837.
• Used the Rational Unified process methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams using the Rational Rose..
• Updated the requirements and prepared comprehensive Business Requirements Document (BRD) that provided the appropriate scope for the users and management to make appropriate decisions.
• Developed associated project documentation, schedule, design specifications, test plan, test scenarios/scripts, performed gap analysis, and test tracking reporting/monitoring for all phases of testing including B2B user acceptance testing.
• Played a key role in planning UAT and implementation of system enhancements and data migration and conversions.

Environment: Microsoft Visio, Windows XP, Facets, MS Office, ITIL, Rational Requisite Pro Quality Center, SQL.

Confidential, Jefferson City, MO

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
• Strong visual modeling and business process modeling skills in Rational Unified Process (RUP) and Agile Modeling with tools like MS Visio
• Worked with team leaders and supervisors to ensure project and organizational deadlines are met
• Used RUP-iterative process to conduct Data Analysis on the feed to be sent to PSGL to find missing data fields in application and aggregation rules.
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Coordinated updates with client's staff and implement efficiencies in documentation maintenance.
• Conducted JAD sessions to complete the prerequisite for the Business Requirement
• Created Use Case, Sequence, Activity and Entity-Relation Diagrams to illustrate for testing effort
• Responsible for doing the gap analysis for the interfacing system.
• Extensively worked with HIPAA Privacy Facets application groups.
• Documented the Business Requirements Document (BRD) and the Functional Specification Document (FSD).
• Used SQL queries for Data Validation and Verification
• Resolved/tracked production issues with Reports in Cognos and Mainframe.
• Facilitated requirements gathering activities, including meeting with users to discuss System Task Requests (STRs), Enhancements, and Project Assessment Quotations (PAQs) requirements.
• Documented issues and resolutions, and wrote specific requirements for system changes.

Environment: Windows, UNIX, Oracle, Requisite Pro, Mainframe, MS Office, Visio.