SUMMARY

• A Senior Analyst with Over 8 years of diversified experience in areas like Business / Data Analysis, Project Management and Testing.
• Extensive experience Healthcare and Insurance applications.
• Designed the ETL system for populating the Datawarehouse from the operational DBMS
• Knowledge and vast experience of PMBOK and BABOK.
• Well Familiar with current industry standards, such as HIPAA, SOX, ISO, Six Sigma, and Capability Maturity Model CMM .
• Strong experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C D, and Insurance Claims.
• Extensive experience on interaction with system users in gathering business requirements and involved in developing projects. Chaired and conducted JAD sessions with business and technical teams.
• Expert in analyzing/troubleshooting and providing technical support for Oracle/Unix applications and their interfaces.
• Worked extensively in Data consolidation and harmonization
• Experience in Data alignment and Data cleansing
• Strong knowledge of Data Integration, validation and processing methodologies.
• Experience in Data Analysis using PL/SQL.
• Vast experience of working in the area data management including data analysis, gap analysis and data mapping.
• Worked extensively with Dimensional Modeling and Data Migration.
• Expertise in SQL and PL/SQL programming -Functions, Stored Procedures and Triggers.
• Experience in working with Microsoft Office suite word, excel, Access, Visio, Power Point and Outlook for documentation, analysis and presentation.
• Worked with HL7, EDI ANSI 4010 Standards
• Strong knowledge of HIPAA EDI , ICD, OIR, CMS, Claims, Under Writing, Membership / Billing, Medicare, Medicaid, Claims and Medical management systems.
• Solid understanding of SLDC, Waterfall and Agile / SCRUM User Stories and Use cases
• Expertise in Software Development Life Cycle SDLC , Use Cases, Business Process Modeling Notation BPMN , Object-oriented Analysis and Design, Rational Unified Process RUP and Rational tools used during all four phases of RUP: Inception, Elaboration, Construction, and Transition.
• 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.
• Knowledge of 837, 835, 277, 270, 271, NCPDP, 5010 and ICD-10.
• Good knowledge of Health Insurance Plans Medicare Part A, B, C and D , managed care concepts Medicaid and Medicare and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience in conducting Gap Analysis GAP , User Acceptance Testing UAT , SWOT analysis, Cost benefit analysis and ROI analysis.
• Extensive knowledge of Medical Management Information Systems MMIS , and National Provider Identification NPI .
• Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270, 271 for healthcare benefits and eligibility, 276, 277 for claims status and 278 for transmitting health care service information.
• Authored test plans, test cases for various test scenarios and helped testing team to better understand the test scripts.
• Executed Test Cases Manually, once the application is stable and documented the successful or unsuccessful completion of each test case in HP Quality Center QC for End-to-End Scenario based testing.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases Test Scripts that are executed during testing process.
• Established traceability matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.
• Extensive experience working in back end tester by writing SQL Queries and PL/SQL scripts on large data warehouse systems involving Terabytes worth of data.
• Experienced in creating Business Requirement Documents, User Requirement Specification, Functional Requirement Specifications, Models and RPF.
• Worked on Facets a product for Healthcare Insurance sector. Good working knowledge of Claims processing, HIPAA Regulations and 270, 837P, 837I, 837D EDI Transactions for health care industries.
• FACETS experience in the areas of Enrollment, Enrollment Pre-processing 834 proprietary enrollment file mapping, Business rules design Enrollment Keyword creation MMS Batch processing, Provider, and Claims Strong understanding of test plans, test cases, test scripts and defects tracking/reporting
• Well versed with ICD9, CPT, HIPPA, claim adjustments, claim processing claim review, identifying claims processing problems, their source and providing alternative solutions.
• Experienced in creating Data Flow Diagrams, Use Cases, Use Case Diagrams, Activity diagrams, Entity Relationship Diagrams
• Experience in Forward Mapping and Backward mapping analysis of ICD 9 ICD 10 Conversion for CM Diagnosis Codes and PCS Procedure Codes ..
• Well versed in Process Narratives, Flow charting Techniques using UML, and Good Documentation Practices.
• Experienced in developing Object Oriented Analysis and Design Models Use Case Model and UML.
• Good Knowledge of Unified Modeling Language UML , Class Diagrams, Use Case Diagrams, Activity Diagrams, Sequence Diagrams.

TECHNICAL SKILLS

C , SQL, HTML, SAS ,MS-Access, Oracle PL/SQL, ASP.NET, MS SQL Server, DB2, Microsoft .NET, Frameworks, ASP.NET, SAP, Flash, JavaScript, PVCS Tracker, and SharePoint, HTML, XML, Macromedia Dream Weaver, MS-Front Page , MS Word, MS Excel, MS PowerPoint Lotus, HTTP, TCP/IP, FTP,MS-Visio, Rational Rose, Irise User Experience ,MS-Project, PVCS Tracker,SDLC, SDM, Agile, Waterfall, Object Oriented Analysis and Design OOAD , Rational Unified Process RUP , Unified Modeling Language UML , Rapid Application Development RAD , Joint Application Development JAD

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business System Analyst/Data Analyst

Confidential is a leading health insurance provider covering the regions of New Jersey state. This project, Care Radius, involves developing a new unified case management system tobe used by both Confidential to better manage their clients various case programs. Within CareRadius, I have been involved in the Lead database project. The Lead DB project strives to create a new Lead case management system in CareRadius to mnage the client lead level cases.

Responsibilities

• Interfaced with the client as part of the Requirements Engineering team to finalize the project scope. Assisted the PM in developing Use Cases and project plans and also managed changes to the scope of the project.
• Extracted the Business Requirements from the client and end users keeping in mind their need for the application Internet, Claims, Provider, and Recipient and documented it for the developers following the HIPAA Guidelines for an Individual functional area by conducting JAD sessions
• Organized Joint Application Development JAD sessions with data steward and ETL teams while having walkthroughs for mapping documents.
• Mapped high-level to-be designs using Business Process Modeling Notation BPMN on MS Visio.
• Experience in implementing and managing the implementation of software, hardware and hybrid solutions to enable Electronic Health Records EHR and Health Information Exchanges HIE .
• Met with the Provider Communities and Trading Partners to ensure that HIPAA transactions pass the EDI gateway and interpret technical difficulties into simple language.
• Worked Extensively with Inbound 837 I and 837 P, 835s Out bounds claims processing systems
• Monitored and assisted in designing and development of Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Analyzed and translated business requirements into system specifications utilizing UML and Agile methodology.
• Met with the Provider Communities and Trading Partners to ensure that HIPAA transactions pass the EDI gateway and interpret technical difficulties into simple language.
• Involved in writing Test plans, Test cases and responsible for executing the Test Scripts.
• Designed a high level spec document to show various paths that need to be taken into consideration for the transformation phase of 4010 to 5010.
• Created Use Cases from the list of requirements and prepared use case diagrams using Rational Rose.
• Prepared Test plans and assisted the QA team in Unit testing and Integration testing.
• Worked with the business users, management and IT users in gathering the technical requirements.
• Wrote Technical requirements, process flows and requirements tracability matrices to document and track the project progress.

Confidential

Sr. Business Analyst /Data Analyst

The project was to develop a customized pricing solution for the organization's complex need and also to develop a Provider Network Management solution for managing complex contractual negotiations with the providers. Confidential was using Confidential Facets 4.71 as their health plan administration system and the Organization was looking for a pricing solution and network management solution to meet their growing customer demands for faster processing and simplifying administration.

Responsibilities

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Extensively involved in data modeling
• Provided full life cycle support for company's Facets enhancement to Facets e2 Workflow and Network Management Suite with Pricing Modeler and Network Modeler application--including Business Requirement gathering, Functional Design, Technical Design, and Production Support documentation for multiple outgoing interfaces.
• Gathered legacy system requirements by shadowing Customer Service Representatives CSRs , Customer Relationship Representatives CRRs , preparing questionnaires, to identify limitations in the current system and GAPS in the proposed system.
• Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
• Worked on changes for HIPAA Transaction and proposed changes to be made in the current system for an easy transition from version 4010 to 5010.
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements
• Experience in Customer Service Request handling
• 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.
• Designed and Developed ETL Extract, Transformation Load strategy to populate the Data Warehouse from the various source systems feeds using Informatica PowerMart, PL/SQL.
• Worked on the MMIS Medicaid Management Information Systems .
• Worked on HIPAA 5010 and ICD10 mandated changes passed 1/16/09 by CMS HHS
• Performed Data Analysis using procedures and functions in PL/SQL.
• Researched upstream data sources and ensured all source data sources were attested by its owners.
• Responsible for creating mapping documents required for the ETL team.
• Created report specifications containing mapping to source data sources.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Performed Data Analysis, writing SQL Queries for Testing and Troubleshooting against Data Warehouse.
• Collaborated with management and senior-level engineers to develop code for new features used within a Health Information Exchange HIE .
• Worked with FDA guidelines 21CFR , HIPAA Health Insurance Portability and Accountability Act .
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes
• Using MITA improved managing and monitoring of programs through the sharing of data.
• Used Facets 4.71 to receive, store and send HIPAA-standard transactions 835, 837, 270, 271, 276, 277 and to administer HIPAA privacy rights.
• Mapped provider data from source to target Facets 4.71 data layout for the claims and benefit configuration.
• Participated in Facets Table data modeling planning, designing, implementation of the data warehouse and conducted testing by developing complex SQL queries.
• Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using Rational Rose / MS Visio / BPMN towards facilitating clear understanding of the business process.
• Supported SOA, data warehousing, data mining, and Enterprise Service model standards in designs, and developed standardization of processes like configuration management.
• Created the conceptual, Logical and Physical Model for the data warehouse with emphasis mutual funds and annuity using Erwin data modeling tool.
• Developed HL7 messaging for bi-directional case and disease report exchange, in text and XML formats, in accordance with HL7 specifications
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Used the CMMI Model to guide process improvement across a project
• Experience in providing the backward compatibility from Facets 4.71 to all earlier versions.
• Identified authoritative data sources specified business rules for data feeds utilizing HL7 protocol.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Responsible for conducting gap analysis as is to be for ICD9 and ICD10. Prepared Data Flow Models for code sets validating in Facets and Claim Process Engine.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Responsible for GAP analysis of ICD9-ICD10.
• Created test plans, test cases and test scripts for UAT.
• Created test scripts and plans for UAT Phase

Confidential

Data Analyst

Project involves catering to the Confidential Department of Medicaid. The role is to understand the Confidential Transactions, Pharmacy Transactions from an Confidential perspective and current Confidential codes being used by the State. The objective is to conduct a gap impact analysis in order to adhere to HIPAA Compliances required by Confidential.

Responsibilities

• Wrote Business Cases after conducting meetings with business users, risk team and finance team.
• Acted as IO Analyst and worked closely with IO Manager, BU Sponsor and BU Contact. Measured business opportunity, description of solution and scope. Measured and documented Labor and Material Detail, Skill Set, Budget Cost to Achieve CTA Summary, Inflow Summary and Economic Analysis.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI's 837, 835, and 834 and ICD-10 Code sets.
• Was responsible for data mapping of HL7 messages into relational database.
• Develop, design and implement department plan to operationalize new FACETS integrated processing system, to include but not limited to workflow, management oversight and performance analysis.
• Facilitated Change Control Board and Governance Board CCB meetings and acted as a liaison between parties impacted by the change requests.
• Developed straightforward RDBMS queries, knowledge of HL7 and xml interface messaging.
• Familiar with HIPAA EDI transactions such as 835, 837 P, D, I 276, 277, 278 etc
• Mapped all as-is business processes using BPMN standards on MS Visio.
• Conducted JAD sessions and created functional and technical requirement specification for application development based on Solution Delivery Process.
• Created a test plan and a test suite to validate the data extraction, data transformation and data load and used SQL and Microsoft Excel.
• Developed estimates, project plans Microsoft project , training material, BI reports using Microstrategy
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Experience with 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.
• Used the BPMN to GAP Analysis to bridge the gap between business processes.
• Coordinated end to end testing efforts of the HIPAA Compliance and EDI Transactions. Ran queries monthly to verify tie-outs for the business prepared by the technical resource to provide support for applications solutions supported by the Reporting and Analytic Finance team with emphasis on the Corporate Finance Cognos Planning Models.
• Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, Websphere and Cognos.
• Performed Impact Analysis and Gap Analysis.
• Responsible for conducting gap analysis as is to be for ICD9 and ICD10. Prepared Data Flow Models for code sets validating in Facets and Claim Process Engine.
• Recommended changes for improvement after analyzing operational procedures and methods.
• Documented issue list and risk list pertaining to various projects.
• Creation of Gap Impact Analysis and Operational Analysis Document for Medicaid Subrogation Wrote use cases and verified that they match every single requirement of the application.
• Prototyped the application, provided screen shots for better visualizations. Coordinated and collaborated the business, operations and the technical areas throughout the project life cycle.
• Create presentation style reports with chart and graphs which can be used to access any type of data source Presented reports to management and provided user training and acceptance tests.
• Performed manual testing and recorded results in Clear Quest and used SQL queries for enhancements. Performed the user acceptance testing.

Confidential

Business Analyst

Confidential operates as a managed healthcare company in the Confidential. The company's Health Plan and Medical Services segment provides health plan commercial risk, Medicare advantage, and Medicaid products. It also offers commercial risk products, including health maintenance organization, preferred provider organization, and point of service products to individuals and employer groups. National in scope, yet local in focus, Coventry's Medicaid expertise helps communities around the nation support their Medicaid recipients gain control over their health challenges. The project was to upgrade the system that currently uses HIPAA 4010 to comply with HIPAA 5010.Gap Analysis was performed and changes were identified in HIPAA 5010 so as to upgrade the Medicaid Management information System MMIS to comply with the new standards mandated by HIPAA.

Responsibilities

• Conducted user interviews at both in-house and client locations, gathering and analyzing requirements using Requisite Pro and Requisite Web
• Organized Joint Application Development JAD sessions with ETL team while having walkthroughs for mapping documents.
• Proactively search for opportunities to increase UX efficiencies
• Extensively used Agile Methodology in the process of the project management based on SDLC.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, Object Oriented Design OOD using UML
• Worked extensively in Data consolidation and harmonization
• Gathered and documented Business Requirements, created Functional specifications and translated them into Software Requirement Specifications.
• Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirements
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Used Facets 4.51 to receive, store and send HIPAA-standard transactions 835, 837, 270, 271, 276, 277 and to administer HIPAA privacy rights.
• Developed test cases and test scripts and assisted Quality Assurance activities, with system integration testing and user acceptance testing UAT , developing and maintaining quality procedures and ensuring that appropriate documentation is in place.
• Involved in claim adjudication process of FACETS application.
• Used Trizetto Product NetworX Pricer and the terms used in the Pricer.
• Interacted with Subject Matter Experts SME , claimers, customers Conducted detailed interviews with them, recorded the requirements, and reviewed the gathered requirement by both technical and business people.
• Responsible for identifying and documenting business rules and creating detailed Use Cases
• Developed ETL mappings, testing, correction and enhancement and resolved data integrity issues.
• Identified the source and target tables. Developed mapping document using MS excel.
• Design, development, implementation and roll-out of Microstrategy Business Intelligence applications.
• Determined the natural keys for the target tables.
• Created the conceptual, Logical and Physical Model for the data warehouse with emphasis on insurance life and health , mutual funds and annuity using Erwin data modeling tool.
• Participated in the process of internal and external auditing activities and developed timelines for project delivery, and managed projects and resources to successful completion
• Mapped provider data from source to target Facets 4.71 data layout for the claims and benefit configuration.
• Responsible for executing User Interface Testing, System Testing, Data Quality Testing on the configuration design and prototypes in Facets 4.51.
• Participated in frequent Agile team meetings Scrum planning, daily stand-ups, retrospectives to provide UX input and guidance to an Agile product development process.
• Experience working with Health Care Client Server Product TRIZETTO FACETS
• Involved in data dictionary management, extraction, transformation and loading ETL of data from various sources. Participated in ETL requirements process during data transition from source systems to target systems
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Involved in Data Analysis Mapping to track all data elements used in the application from the user interface through different interfaces to the target databases in which they are stored.
• Developed tables, Views, Stored Procedures and Triggers using SQL Scripting
• Established Inner Join, Outer Join and created Indexes whenever necessary
• Facilitated internal review sessions with the BI and ETL team and external review sessions.
• Writing Complex SQL queries and optimizing SQL Queries.
• Documented Medicare claims processing.
• Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize FACETS features not provided by the legacy systems.
• Responsible to meet the information demands of our business users by delivering timely, accurate, meaningful and standardized data and reporting
• Participated in creating logical and physical data models, their enhancement. Based on the data models, worked with business architect, to create the software solution models.
• Helped in creating of Data-Mapping best practices document including visual processes and trained team members on Data Mapping process and tools.

Confidential

Business Analyst

Confidential as a Medicare contracted Health Management Organization is qualified to provide such service to its members with its unique and comprehensive Medical Center benefits. I worked as Business analyst to work closely with project team to identify user's business requirements, interpret complex business needs and translate them into system requirements, write business specifications and forward to technical staff for system integration.

Responsibilities

• Facilitated collection of functional requirements from system users, and prepared business and technical requirement specification documents.
• Write and execute positive and negative test cases to ensure the data originating from the data warehouse Oracle dB is accurate through to the SQL dB in the applications.
• Senior level SQL query skills Oracle and TSQL in analyzing and validating SSIS ETL database data ware house processes.
• Facilitated review of Enrollment, Claims, Commissions, and membership portlets' designs with architects and developers to ensure that the goals of the portal requirements were satisfied
• Used UML, for gathering requirements, created Use Case Diagrams, and Use Case Specification document USD .
• Tracking and managing requirement changes using Requisite Pro.
• Assisted in building a Business Intelligence Process Model using Rational Rose and Visio.
• Extensively involved in the modeling and development of Reporting Data Warehousing System.
• Used Prototyping method to gather additional requirements from the users in order to describe the business needs in terms of the system being created.
• Responsible for the development and implementation of documentation standards, naming conventions, templates and process documents for CMMI certification.
• Prioritized project efforts, developed project plans, process flows, Use Cases and SRS using RUP.
• Experience in implementing and managing the implementation of software, hardware and hybrid solutions to enable Electronic Health Records EHR and Health Information Exchanges HIE
• Followed the RUP based methods using Rational Rose to create: Use Cases, Activity Diagrams / State Chart Diagrams, Sequence Diagrams.
• Gathered requirements and modeled the data warehouse and the underlying transactional database
• Provide business intelligence analysis to decision-makers using an interactive OLAP tool
• Captured, communicated, managed system requirements and Maintained requirement tractability to keep team members up to date with the latest requirements and changes if any.
• Formatted HL7 messages for interface applications to Cloverleaf interface engine.
• Responsible for training and testing of transactions.
• Successfully implemented AGILE methodology for application development.
• Involved in creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Execution of test scripts using WINRUNNER, TESTDIRECTOR.