Career Summary:

• System Analyst with over 7 years of experience in Healthcare and Pharmacy domain.
• Extensive working experience with Confidential tool.
• Profound understanding of insurance policies like HMO and PPO and proven experience with HIPPA 4010/5010 EDI transaction codes such as 270/271 inquire/response health care benefits , 276/277 Claim status , 834 Benefit enrollment , 837 Health care claim .
• Experience with Trizetto Facets 4.71, 4.81 and 5.01.
• Excellent working knowledge of SQL Server Reporting Services SSRS , SQL Server Integration Services SSIS , SQL Server Analysis Services SSAS .
• Ensured accurate Transmission of the eligibility file and membership file to vendors and delegates as a result of the annual benefit changes.
• Experience in Forward mapping and backward Mapping analysis of ICD 9 ICD 10 conversion for CM Diagnosis Codes and PCS Procedure Codes .
• Expertise in EDI HIPAA 4010-5010 project to convert EDI x12 healthcare 4010 transactions into 5010 complaint transactions.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider and Billing Modules of Facets.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Provided analytical solution to the customers for Facets Production Issues.
• Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Strong knowledge of Use Cases, Sequence Diagrams, Collaboration Diagrams, Activity Diagrams, and Class Diagrams.
• Experienced in creating Use cases, Cross-functional flowcharts, activity diagrams and sequence diagrams.
• Extensive experience in Functional, Integration, Regression, User Acceptance UAT , System, Load and Black Box Testing.
• Provided major corporate clients with reports documenting the re-engineering process for identified administrative tasks and functions which included defined goals, objectives, critical success factors, cost analysis, administrative analysis and recommendations.
• BA/PM to evaluate business pain points, designed and implemented Business Process Reengineering methodology, and to improve business revenue through improved employee performance. cost, service, quality and speed
• Good Management, Execution and Documentation skills
• Expert in application/system development life-cycles concurrent development strategies, process streamlining, iteration modeling, rapid application development RAD/RUP/UML , and legacy/waterfall methodologies.
• Excellent knowledge of MS Office especially MS Excel, Power Point, Word etc

Business Skills:

• Business Plan development and requirement gathering and documentation
• Business case development including use cases and test scripts.
• Gap analysis reporting of 'as-is' and 'to-be' business environments.
• Iterative approach to project deliverables, including JAD sessions and peer review.
• Project management support through performance metrics and risks management logs.
• Technical Expertise:
• Modeling Methodologies Agile, Rational Unified Process RUP and Waterfall
• Process/ Modeling Tools Rational Rose, MS Visio, Lombardi
• Databases MS Access, SQL Server, SSIS SSAS SSRS
• Quality Management HIPAA, CMMI, CMM
• Languages SQL HTML, C, C
• Operating System WINDOWS 98/2000/NT/XP
• Office Tools MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, SharePoint
• Project Management MS Project
• Healthcare Tools Trizetto Facets 4.51, Claredi, Amisys, QNXT

Professional Experience:

Confidential

Sr. Business Systems Analyst

• Description: Confidential major service lines include workers compensation claims administration and healthcare management services, property and casualty claims management, class action services and risk management information services.
• As a Business Analyst in Confidential I performed pivotal role in multiple projects handling three releases at the same time. Release 1 2 was web-based service application developed for streamlining office workflow processes involved in Electronic Data Interchange EDI transactions and benefits in claims management cycle based on HIPAA Guidelines. Release three was based on reporting the policy premium. There were seven reports, which were generated in Confidential portal.

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Experience in Medicaid Management Information System MMIS . Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis PDD , Explanation of Benefits EOB .
• Extensive hands-on and HealthCare management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support the Medical Management Information System MMIS as well as day-to-day business operations.
• Used the requirement attributes priority, effort, and risk as the basis for negotiating the inclusion of the requirement, to manage the scope of the system efficiently.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Involved with the QA team to Conceptualize, determine and develop test approaches and methods for Unit testing, Integration and Functional testing, Load and Usability testing according to the application complexity and test requirements.
• Implemented Data Modeling standards, including element-naming conventions.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Used SDLC System Development Life Cycle methodologies like the RUP and the waterfall.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process Pre-Adjudication .
• Worked intensively on FACETS 4.6.1 for audit trails made on the used account and check and store information related to the HIPPA authorizations
• Experience in Claims Processing per Medicaid Management Information Systems MMIS 42 CFR 433
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 P.I.D to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Set claim processing data for different Facets Module.
• Tested HIPAA regulations in Facets HIPAA privacy module.
• Tested and delivered Inbound/Outbound Facets interfaces.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Wrote Procedure Manuals and was responsible for continuity preparedness.
• Evaluated testing results for each potential release build using Test Director, Quality Center and Bugzilla reports, listing summarized bug information in priority sequence, recommended viability of release for production.
• Created business plans for integration of front end applications to communication with the back end mainframe.
• Helped in writing Training manuals and helped business with the Training on a one to one sessions.
• Evaluated testing results for each potential release build using Test Director, Quality Center and Bugzilla reports, listing summarized bug information in priority sequence, recommended viability of release for production.

Environment: Windows, OBIEE 10.1.3.4.1, Windows, Window NT, Linux, Mainframe, Solaris IBM Web sphere, Apache Tomcat, IIS 6.0, Web Logic, Java, SharePoint, MS Office, Quick Test Pro 8.2, Mercury Quality Center 9.0, Load Runner 8.2, Sun Java, MSJVM, Oracle 8i/9i/10g, SQL Server, DB2, Toad, MS-Project.

Confidential

Business Analyst

Description: The Company serves Medicare beneficiaries and individuals through its Confidential plans. I worked on the claims processing module of the Group Approval Process GAP . The claims processing module involved Receipt and Verification of Claim Forms 837 and Claims Attachments 275 , Claims Enquiry and Response 276/277 , Adjudication, EFT and ERA 835 as per HIPAA guidelines.

As Business Analyst Responsibilities:

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Performed Cost benefit, ROI and ROM studies
• Conducted user interviews and documented business and functional requirements.
• Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System MMIS
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Led and managed the User Acceptance Testing UAT for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Provided business and mapping expertise during a transition of the EDI applications from the GXS Application Integrator AI to GIS.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Involved in creating business processes and modeling diagrams using Rational Unified Process RUP .
• Created use case scenarios and documented work flow and business process using Rational Rose
• Involved in project management using MS Project
• Documented requirements, associated change requests with requirements and connected requirements with Use cases.
• Confidential to create Requirement Document Specifications using Visible Analyst.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Used Rational Clear case for version control
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle SDLC methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.
• Queried database using SQL for backend testing
• Used Rational clear quest for defect management

As Quality Assurance Analyst Responsibilities:

• While working on requirements of the 835 HIPAA project, jumped half way in the 820 report project, continued working on 835, 276 / 277 and HIPAA EDI Transactions across enterprise, meanwhile new project initiation of 4010 to 5010 migration began
• Used TriZetto HIPAA Gateway to comply with HIPAA standards 270/271, 276/277 837 for EDI transactions
• Tested the ANSI X12 Version 4010 / EDI transactions HIPAA like 270, 271, 837P, 837I, 835 remittances
• Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrollment and benefits, batch jobs corresponding to the claims 837 and real time transactions like 270/271/276/277
• Did the forward and reverse data mapping between the fields in mainframe and QNXT.

Environment: MS SQL Server 2005, Rational Reqpro, Rational Manual Tester, Rational Test Manager, MS Share Point

Confidential

Business System Analyst

The project was primarily getting the organization ready for Confidential standards. This would involve analyzing the claims that come from healthcare providers and see how the change in coding is impacting the legacy systems. All this would have a great impact on the existing claims processing policies, procedures and processes such claim receipts, claims reimbursements, claims reporting etc.

Responsibilities:

• Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates generated and maintained clinical data security policies and procedures.
• Created SOW for documenting established procedures.
• Documenting the impact of codes and the corresponding crosswalks associated with the claims and benefits on payer side.
• Worked on Data Mapping to map Facets data to outbound eligibility extracts
• Involved in claims submission and payment remittance retrievals by using ASC x12N 834 for the Inbound Enrollment and Maintenance ASCX12 276/277 for the claims status enquiry and response and ASC X12 835 Explanation of Benefits for the healthcare claim payments.
• Built, implemented and supported system solutions for Facets applications
• Identify and address areas of discontinuity between ICD 9 and ICD10 so as to avoid unnecessary mappings.
• Created documents on medical case management.
• Help in preparing the training material and other documentation materials of the providers and insurance companies using the software supporting ICD 10.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process Pre-Adjudication
• Involved in claim adjudication process of facets application
• Worked on the EDI 834-file load to Facets through MMS Membership maintenance sub-system
• Worked with FACETS edits and EDI HIPAA Claims 837/835/834 processing.
• Worked with FACETS, E-Billing and EDI HIPAA Claims 837/835/834 processing including Medicaid.
• Tested the HIPPA EDI, 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.
• Provide input to estimates for project management and change management activities through analysis of requirements effort, resources, and technology.
• 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
• Supported QA in the definition and execution of integration and system testing.
• Negotiated and managed multiple priorities, project plans, time frames and trade-offs while ensuring the clinical and administrative staff understood the final results of the projects, sharing detailed vision of cost-benefit analysis
• Created reports to satisfy user requests, data sampling, project analysis, or testing verification
• Used the Rational Unified process methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams using the Rational Rose.
• Created Meeting of Minutes documents that would cover all the important issues and decisions taken internally as well as with the client.
• Worked on cross-functional team to deliver software systems as per the customer expectations.
• Updated the requirements and prepared comprehensive Business Requirements Document BRD that provided the appropriate scope for the users and management to make appropriate decisions.
• Created Data Flow Diagrams DFDs and ER diagrams for domain modeling.
• Played a key role in planning UAT and implementation of system enhancements and data migration and conversions.

Environment: Microsoft Visio, Windows XP, Rational Requisite, Rational Rose, Load Runner, .NET, Oracle

Confidential

Business System Analyst

Confidential. is one of the largest health benefits companies in the Confidential that delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services. I worked for the team that was responsible for tracking and addressing the problems on timely manner encountered by the providers, billers as well as vendor companies. As a Business System Analyst, I was involved in a project that involved updating Managed Care Credit policies based on the Confidential approved changes and HIPAA EDI 834 membership enrollment transaction.

Responsibilities:

• Performed Requirements Gathering and Analysis, interviewed the SME Subject Matter Experts , and ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
• Facilitated Joint Application Development JAD Sessions for communicating and managing expectations and gathered requirements.
• Created the Business Requirements, performed requirements analysis along with the creation of Use Case Scenarios and modeling of the business and application using Unified Modeling Language UML .
• Performed Gap analysis to understand the differences between existing system and proposed system.
• Worked with Business Owners to ensure that Eligibility and Membership File exchanged on daily and weekly basis is updated with the Medicare changes.
• Ensured that application was created and maintained in a manner that supports the departmental, user and overall business objectives in coordination with other system vendor products.
• Experience in working and conducting requirement engineering process and Business process Analysis.
• Worked as liaison between software developers and users of EHR systems to create better electronic medical record systems.
• Translated and transferred requirements from Business Requirements Document BRD to Functional Requirement Document FRD .
• Designed Activity, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate member selection criteria.
• Enabled successful implementation and usage of the File Transfer Protocol for the extract submission to the corresponding vendor.
• Experience with Trizetto Facets System especially with the Managed Care Credit policies.
• Experienced with Trizetto Facets System membership enrollment involving HIPAA EDI 834.
• Was involved in discovering defects in the system using Mercury Quality Center and User Acceptance Test using the test cases given by the client before releasing the application.

Environment: Facets 4.7, Microsoft Office 2007, Oracle 9i, HP Quality Center 9.0, UML 2.3.1, MS Visio 2007, MS SQL Server 8.0, MS SharePoint 2.0, Trizetto facets 4.7.

Confidential

Business System Analyst

CONFIDENTIAL is the largest Health Maintenance organization in Confidential. There are nine different regions and a single common website linking all the regions. CONFIDENTIAL is a consortium of three distinct groups of entities: the Confidential and its regional operating organizations, Confidential, and the Permanente Medical Groups.

Responsibilities:

• Performed Requirements Gathering and Analysis, interviewed the SME Subject Matter Experts , and ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
• Facilitated Joint Application Development JAD Sessions for communicating and managing expectations.
• Use HIPAA transactions to interface with Third-Party Administrators TPA also various proprietary file interfaces for TPAs not supporting HIPAA transactions.
• Develop health and welfare fund and/or TPA to administer all member benefits and payment.
• Design Plans to pay provider based on specific reimbursement arrangement.
• Manage the Requirements Business as well as System requirements , performed requirements analysis along with the creation of Use Case Scenarios. Modeling of the business and application using Rational Unified Processing RUP and Unified Modeling Language UML .
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation Verification process.
• Created Process Work Flows, Functional Specifications, and responsible for preparing Functional Specification Document FSD .
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the proposed system.
• Support Internal and external auditors for department audit.
• Performed Defect Tracking and Change Control Procedures using Quality Center and Configuration Management and Version Control using Rational Clear Case.
• Participated in developing test plans and test procedure templates and guidelines to be used by the project team with detailed screen layouts with regards to various types of corporate actions.
• Was involved in Functional System Testing, Integration Testing, Regression Testing, and User Acceptance Test using the test cases given by the client before releasing the application.
• Involved in the development of Test Plans, Test Cases and Expected Results, and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Provided assistance in other concurrent projects, especially in Regression Testing, in order for the team to gain time, before the clients could proceed to the system's User Acceptance Testing UAT
• Effectively logged and managed defects found during project system testing, and successfully interacted with the offshore development team to provide input for system fixes.

Environment: M.S Word, Excel, PowerPoint, SQL, MS Visio, Rational Tools, MS Access