SUMMARY

• Around 7 years of experience in the field of Information Technology in the Healthcare - Life Sciences / Pharmaceutical / Pharmacy Benefit Management (PBM) / Insurance domain encompassing business systems planning, procedural development, reporting and validation.
• Experienced in Requirement Gathering, Systems Planning, Procedural Development & Implementation, Business Process Mapping, Problem Solving/Workarounds and Business Contingency Planning/Disaster Recovery, Creation of Domain Models and Creating Reports for Analytics.
• Extensive experience in Business Requirements gathering and writing skills with expertise in developing and documenting Business Requirement document (BRD), Functional Requirement Document (FRD),Software Requirement Specification (SRS) and Requirement Traceability Matrix (RTM) across the deliverables of a project. Hands on experience in all phases of DataModeling-Conceptual, Logical and Physicalmodeling.Experience in data transformation, data mapping from source to target database schemas, data cleansing procedures.
• Knowledge of 837, 835, 277, 270, 271, NCPDP, 4010, 5010 and ICD-9/ICD-10.
• Experience with TriZetto Facets and TriZetto HIPAA Gateway - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Understanding and mapping of the various ICD9/ICD10 Codes applicable for tracking of diseases for which diagnostic testing is done in the area of BioChemistry.
• Worked with a tool set for creating crosswalk mapping rules and business rules to convert ICD-9 to ICD-10. Utilized CMS GEMs (General Equivalency Mapping) crosswalk mapping file.
• Knowledge and experience in implementation of HIPAA and NCPDP standards.
• Designed High level design, for New process, integrating with legacy and Facets
• Experience in preparing documentation which is in compliance with 21 CFR Part 11, Medicare Part D requirements, HIPAA ANSI X12 Transaction sets, and in accordance with NCPDP (National Council for Prescription Drug Programs) Standards. Experience in writing SQL queries and optimizing the queries in Sybase, Oracle and SQL Server.
• Responsible for integrating with Facets .Designing test scripts for testing of Claims in Development, Integration and production environment.
• Worked as (in) a team with Account Management, Company Management to document requirements, process flows, wire frames, for corporate accounts/external clients.
• Application of Software Development Life Cycle (SDLC), with thorough understanding of various phases such as Requirements, Analysis/Design, Development, Testing and Implementation.
• Extensive experience with Business Use Cases, Functional Use Cases, Business Process Models, Test Cases.
• Extensive experience in process modeling using UML, flowcharts, sequence diagrams, activity and diagrams.
• Strong knowledge of UML, RUP, Rational Suite including Rational Rose Requisite Pro, Clear Quest and Clear Case, Microsoft Visio.
• Experience working with Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system, and conversion of ICD-9 to ICD-10.
• Experienced in conducting Joint Application Development (JAD) sessions with SMEs, Business Analysts, Software Developers and Quality Assurance teams for New Corporate Accounts or Clients.
• Worked on Six Sigma tools such as Ishikawa Diagram (Root Cause analysis), FMEA, SIPOC, ANOVA and QFD.
• Excellent communication, interpersonal, analytical skills and strong ability to perform as part of a team in for four years in CMMI accredited and CMS Compliant (Medicare Part D) companies.
• Worked with ETL Developers and Process Analysts in preparing the requirements (data and functional), and writing (documenting) work flows and process flows
• Understanding of the Lab Requirements mandated by the College of American Pathologists
• Strong attention to detail and proficient in working in high pressure environments with tight deadlines
• Experience with Data Warehousing and Business Intelligence Tools like Informatica, Business Objects, Broadcast Agent, and Web Intelligence
• Experience with conducting assessments and impact/gap analysis concerning State MMIS

TECHNICAL SKILLS

OLAP & Reporting Tools: Business Objects, Web Intelligence, Broadcast Agent, Crystal Reports, Query Studio, Cognos, Microstrategy

Databases Tools: Oracle, SQL Server, TOAD

Languages: UML, C, UNIX, SQL, Java

Business Tools: MS Visio, Rational Rose Requisite Pro, Clear Quest and Clear Case

M thodologies: SDLC, RUP, JAR, JAD, UML

Other Software: MS Visio, MS Word 97/2000, MS Excel 97/2000, MS Access 97/2000, MS Project

Operating Systems: MS Windows 2000/NT/98/XP, UNIX, MSDOS.

PROFESSIONAL EXPERIENCE

Confidential, Newark, NJ

Sr Business Systems Analyst

Responsibilities:

• Performed Requirement Gathering & Analysis by actively soliciting, analyzing and negotiating customer requirements and prepared the requirements specification document for the application using Microsoft Word.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Analyzed and tested various Common Eligibility Outbound Interface Process and other Inbound/Outbound Facets interfaces.
• Interviewed business users, SMEs, Trading Partner asking detailed questions to gather business requirements, wants, and needs concerning the project and carefully recorded the requirements in a format that can be understood by both business and technical teams.
• Interacted with the Development team to help write technical specifications to describe Functional Requirement Documents (FRD),Business Requirement Documents(BRD), design specifications and module specifications
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Involved in Trizetto Facets System implementation, 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.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Understanding technical solution and product roadmap for different software. Coordination of numerous project initiatives including: system conversion and integration of a behavioral health acquisition, preparation of numerous RFP responses, other system initiatives related to case management, provider management, eligibility management, claims processing, and prior authorizations. Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures. Maintained a deep knowledge of the aspects and complexities involved in testing HIPPA 5010 with direct payers and clearinghouses.
• Involved in Trizetto Facets System implementation, 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.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.
• Actively participated in the enrollment of a large group of provider community to have their ANSI X12 transactions submitted to Florida Medicaid. The database for enrollment was Trading Partner Management System (TPMS). The different submitter types enrolled were Providers, Software Vendors, Clearing Houses and Billing Agents.
• Wrote Use Cases, prepared use case diagrams (using Rational Rose) and followed Rational Unified Process at every stage of the process.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Developed UML Use Case model for the application using MS Visio and assigned to prepare the detailed Work flow diagram based on the proposed enhancement for the system. Create and maintain Use Cases, visual models, including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Coordinated with the data conversion team and Trading Partner during the development, test, and reconciliation process and post implementation FACETS 4.51 and legacy systems data to ensure accuracy and consistency.
• Involved in Up-gradation of HIPAA X12 4010 transactions to HIPAA X12 5010 and ICD-9-CM to ICD-10 CM/PCS (Clinical modification/procedure coding system) simultaneously.
• Creating documentation for sustainable custom development strategy. Designed and developed project document templates based on SDLC methodology. Created SQL reports, data extraction and data loading scripts for different databases and Schemas. Gathered requirements from users of the Clear Quest (CQ) tool for any Enhancements or change requests for any defects. Queried database using SQL for backend testing.
• Responsible for integrating with Facets .Designing test scripts for testing of Claims in Development, Integration and production environment.
• Met with the Provider Communities and Trading Partners to ensure that HIPAA transactions pass the EDI gateway and interpret technical difficulties into simple language.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD 10Code set andANSI X12 5010formats.
• Involved in gap analysis and implementation of HIPAA 5010, ICD 10 and Claim Validations.
• Created DTS Packages for migration of data between MS SQL Server database and other databases like MS Access, MS Excel and Flat Files. Developed data conversion programs for, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Analyzing COTS upgrades and document them. Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Creating documents for technology obsolescence approach. Organized meetings to discuss outstanding issues with QA and developers.
• Analyze and create summary for all products roadmap as well as their improvements and timeline

Environment: MMIS, SharePoint, JAVA, MS Access 2000, MS Excel, RUP, Mainframe, Oracle, MS Word, MS Excel, MS Access, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, ETL, MS Office suite, MS Visio 2003.

Confidential

Sr. Business Systems Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Understanding of POS, Co-Pay Benefit Pricing, Claim Adjudication Protocol
• Initiate, facilitate and manage meetings to address agendas
• Create and drive presentations designed for knowledge transfer and corporate
• Understand the client’s needs and translate it into plausible requirements while working on the Corporate Account requirements. Analyzed trading partner specifications and created business requirement documents for Trading Partners Testing (5010) with direct payers and clearing houses.
• Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Working knowledge of inpatient and outpatient claims processing including ICD-9, ICD 10-CM, ICD-10 PCS, CPT, HCPCS, and set up system related components to ensure accurate claims adjudication by health systems
• Creating Business Rules, User Interface Rules and Use Cases for functionalities captured within the Functional Requirement documents in preparation for HIPAA D.0 changes. Collected Business requirements (BRD) from Business owners for applications. Incorporated Rational Unified Process (RUP) to create Business Requirement Document Specifications using MS Visio, MS Word and MS Excel.
• Work closely with the business stakeholders to extract and secure requirements.
• Identified needed modifications for upcoming ICD9 directives from the then available documents from World Health Organization, and CMS
• Analyzed CMS comparison documentation highlighting changes of 4010 format and ICD9 diagnosis and procedure codes.
• Responsible for integrating with Facets .Designing test scripts for testing of Claims in Development, Integration and production environment.
• Involved in creating sample mappings for the conversion ofEDI X12transactions code sets version and translation ofICD 9codes intoICD 10codes.
• Involved with the coders in evaluation of CPT and ICD-9 codes to ensure that the diagnosis meets medical necessity for the specific CPT code.
• Coordinate with Development to ensure that requirementsare understood
• Collaborate with QA to ensure all set-ups are available and validate results through test cases
• Acquire sign-offs and maintain proper documentation
• Initiate Change Control as per CMMI standard protocol. Worked with Data Extraction, Transformation and Loading. Metadata architecture was also provided, for the purposes of query enhancement and clarification of data relationships. Also built the foundation for process implementation in MS-SQL.
• Conduct Work-Sessions for Work-Around planning. Migrated Data from MS Excel to SQL Server Reporting Service Using DTS and SQL loader utilities.
• Knowledge and experience in creating requirements for HIPAA (EDIX12 Transactions)
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Knowledge and experience in applying NCPDP standards. and experience in Medicare Part D in a CMS Compliant and CMMI
• Understanding and resolving of CMS Compliance issues (Medicare Part D)
• Experience using Agile software development methodologies, including experience creating and managing SCRUM artifacts (User Stories, Product Backlog, facilitating Scrum meetings)

Environment: RUP, JAD Sessions, GAP Analysis, Breeze, Communicator, Clear Quest, Optimal Trace, Rumba, PTS Web, PTS Time, MS Office Suite, Sharepoint, Agile Methodologies

Confidential, Pennsylvania

Business Systems Analyst

Responsibilities:

• Networked with Subject Matter Experts, Project Manager, Developers, and Process Analysts to understand the business process, gathered Business Requirements and identified enhancements.
• Extensively developed project documentation, process flow documents, formal proposals, RFQ’s and RFP’s. Formulated methodologies and developed SDLC phases, strategies, time & cost estimates with milestones for each phase.
• Prepared Business Requirement Documents (BRD’s) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Participated in project meetings to support the team as required, Organized various meeting with SME’s and testing Team to ensure that we are on track with all of our deliverables, tracked all our deliverables on a daily basis by using Deliverables tracking Template. Teamed up with both internal and external software development teams to provide functional requirements specifications in the form of use cases, business process flows, and prototypes and management reporting requirements.
• Designed Data Flow Diagrams (DFD’s), Entity Relationship Diagrams (ERD’s), and web page mock ups using modeling tools. Involved in formatting data stores and generate UML diagrams of logical and physical data. Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Understanding and assessment of the current EDI Transactions used. Understanding and assessment of the current Pharmacy Transactions from an NCPDP 5.1 perspective. Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data. Worked in mainframe environment and used SQL to query various reporting databases.
• Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system.
• Understanding and assessment of the current ICD 9 codes used by the State
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions (837, 835, 276/277, 270/271)
• Creation of a Gap/Impact Analysis Document for changes to Pharmacy Transactions (real time and batch) based on NCPDP 5.1 to NCPDP D.0, specifically concerning the data elements
• Creation of a Mapping Document for ICD9 Codes to ICD 10 Clinical Modifications and Procedural Codes.
• Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System
• Creation of Gap/Impact Analysis Document Operational Analysis Document for the Drug Utilization Review System
• Creation of Gap/Impact Analysis and Operational Analysis Document for Medicaid Subrogation
• Creation of Gap/Impact Analysis Document and Operational Analysis Document for the Drug Rebate Analysis and Management System
• Participated in implementation and understanding of Claims- based EHR. Coordinated, participated and provided guidance to the QA team at every phase of testing performing Phase and Unit testing, System testing and User Acceptance testing.

Environment: MS Office Suite, MMIS, POS, GEMS, Document Analyzer, SharePoint, MS-Visio, MS Excel, MS Access, Mainframe, ETL, UML, Rational Requisite Pro, Rational Rose, Rational Clear Case, Rational Clear Quest, html, JAVA, Asp, MS Window Server.

Confidential, Sacramento, CA

Business Systems Analyst

Responsibilities:

• Extensively involved in every phase of the RUP process starting from Inception to Transition
• Interacted with users for verifying User Requirements, managing Change Control Process, updating existing Documentation. Analysis of Business Requirements, Process Modeling and preparation of Functional Design Specifications employing use case scenarios, sequence diagrams.
• Worked for a project to customize and integrate a Business Process Management (BPM) solution.
• Responsible to write BRD’s containing specifications related to HIPPA 0/271, 276/277 ) for Medicaid and Medicare Payers and other payers
• Documented existing and proposed process flow, analyzed current and target system, and conducted GAP analysis.
• Review Validation Deliverables from the QA perspective using pharmaceutical GxP practices. Conducted review of Development Team design level validation deliverables using pharmaceutical GxP standards and implemented the SharePoint Portal for Vendor Audits.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Designed workflows and allocated permissions within SharePoint.
• Involved in requirement gathering and database design and implementation of star-schema, dimensional data warehouse using Erwin.
• Worked with key members from various cross-functional teams to analyze various third-party CRM solutions to make a ‘buy vs build’ decision. Conducted cost/benefit and impact analysis.
• Conducted Joint Application Development (JAD) sessions with IT groups. Identified the Key Changes, and participated in Stakeholder Management to communicate effectively with them
• Developed and Documented timelines for Project Delivery, and managed Projects and Resources to successful completion.
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Created the business process model using MS Visio for better understanding of the system and presented it to Project Manager and other team members for validation.
• Created and updated the Data Profile Questionnaire through various phases of the project life cycle.
• Lead the effort of Data Migration from disparate data sources into normalized data to eliminate redundant information and organizing the tables to easily maintain the table structures.
• Designed and implemented basic SQL queries for QA Testing and Report / Data Validation.
• Apply UML notations and methodology in developing models that accurately represent the business process reengineering and workflows and clearly communicate them to the stakeholders.
• Designed Data Flow Diagrams (DFD’s), Entity Relationship Diagrams (ERD’s), and web page mock ups using modeling tools.
• Prepared graphical depictions of Use Cases, Business process diagrams, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using Microsoft Visio.
• Worked on data modelling and produced data mapping and data definition documentation
• Used Informatica to extract and transform data from various DB2 database to the data warehouse.
• Conducted User Acceptance Testing, gathered and documented User Manuals and Business Rules

Environment: PowerPoint, UML, XML, SQL, Oracle, Rational Tools, QTP, Rational Suite, Mainframe, ETL, Windows, JAVA,, Crystal Reports, Oracle, UML, MS Word, MS Excel, MS Access, Visio.

Confidential

Business Systems Analyst

Responsibilities:

• Involved in interactions with Subject Matter Expert, Project Manager, Developers, and the end-users in more than one JAD sessions. MS Project proved useful in coordinating activities with project manager and various other teams.
• Designed and developed UML Use Cases, Activity Diagrams, Sequence Diagrams, using UML
• Created use cases and use case diagrams using Rational Rose.
• Gathered product requirements in order to describe the business needs in terms of the main deliverables or products that are created.
• Talked to the end users to create the process requirements and to properly explain the flow of future data modules to the design and development team.
• Analyzed and documented business user & test requirements using Test Director Requirements tab.
• Modeled the information and then came up with the requirements prioritization. Eliminated false requirements by screening out multiple versions of user input. Final prioritization was based on both, product and process requirements.
• Provided clear and concise documentation regarding requirements management plans, functional requirements, supplemental requirements, test plans and test cases.
• Resolved issues related to requirements during system testing and UAT plan preparation.
• Participated in the planning of the User Acceptance testing effort.
• Creation of Test Cases for functional testing of the system. Created the SQL scripts for demonstrating the prototypes and for verifying the result sets.
• Review requirements and create a test strategy to be implemented.
• Helped with data modeling and defining the conceptual and logical model of the data warehouse.
• Involved with the Test planning, test development and test execution.
• Responsible for scheduling meetings with users, SME’s and stakeholders to identify problems resolve issues and improve the process to ensure a stable and accurate solution.
• Create test plans to detail the scope and level of testing that needs to be performed and documented them on PMI share point
• Performed extensive Manual Testing to verify the application is complete and stable.
• Using Workbench to test upcoming and existing Components created in workbench to provide additional content and data requested based of needs for the website.
• Using Workbench to create new content by walking thorough all creation processes and test parameters.
• Identify timelines for the different kinds of testing to be performed and estimate the risks involved.
• Performed test data analysis and ensure data requirements are met prior to start of various testing phases.

Environment: MS Excel, Microsoft Visio, MS-Project, MS-Access, Crystal Report, PL SQL, SQL, Oracle 9i, Unix, WinNT, Win Runner & Test Director