SUMMARY

• Over 7 years of professional experience as Business Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Extensive experience in the development, implementation and integration strategies towards a team oriented environment, utilizing quantitative and qualitative analytical skills. With ease in communicating/converting clients vague/non - technical requirements into precise/concise representation to the team.
• Experience in developing detailed functional specs through JAD sessions, interviews, on site meetings with business users & development team.
• Documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document) and Non-functional Requirement Document.
• Worked in various technologies such as EpicCare Ambulatory, EpicCare Inpatient, IDX/GE Centricity, Cerner PowerChart, Citrix, HL7 (v 2.3/2.4), PACS, DICOM, XML, Java, .Net, Oracle and HTML.
• Strong knowledge and experience in Healthcare industry. Functional knowledge of Medicaid Management Information System (MMIS).
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile & Waterfall life cycle
• Experience in Documentum related technologies and tools like Trusted Content Services, Content Server 5x/6x, e-Content Server 4.2.6,WebTop, Documentum Compliance Manager, Documentum Administrator, Content Services and Archive services for SAP
• Knowledge of Hospital Billing, Charge and Revenue Codes (CPT), HCPCS, ICD-9-CM code books, CMS 1500 professional claim forms and UB-92 hospital claim forms
• Experience in Medicare and Medicaid coverage guidelines.
• Experience in interviewing Business users & SME providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• Test Case writing (manual/automated test cases) and Conducting Tests (Integration testing, Regression testing), Black Box/White Box testing, UAT (User Acceptance Testing).
• Analysis & Design (Use Case, Sequence and Activity diagrams).
• Writing Manuals (System guides, training material for business users and Deployment guides).
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users
• Strong Experience in SQL Server Integration Services (SSIS), Data Transformation Services (DTS) and SQL Server Reporting Services (SSRS)
• Knowledge on different reporting tools (SSRS, Crystal Reports, Cognos, B.O)
• Experienced in designing report layouts in SSRS and deployed cubes using SSAS.
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Knowledge of Medicaid Information Technology Architecture MITA Service Oriented Architecture
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with data analysis, data mapping and dimensional modeling experience in decision support systems (data marts) using Star Schema.
• Good knowledge on different modules within health-care (Membership, billing, enrollment, claims, capitation, providers).
• Knowledge of Electronic Medical Record ( EMR ) and Electronic Health Record ( EHR)
• Knowledge in Health Care Reform and Patient Protection and Affordable Care Act (PPACA)
• Experience with HIPAA compliance (4010 & 5010) and Health care systems
• Experience with Medicare, Medicaid, Medigap/Medsupp & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Experience with health care Systems: FACETS, Medicare Part A, B, C, D, Medicaid systems.

TECHNICAL SKILLS

Methodologies: SDLC, RUP, UM, Agile.

Project Management: Microsoft Project, Microsoft Office.

Modeling Tools: Rational Rose, Microsoft Visio.

Change Management Tools: Rational Requisite Pro, Clear Quest, Test Director.

Version Control Systems: Rational Clear Case.

Testing Tools: Rational Enterprise Suite, Test Director, Win Runner.

Languages: C, C++, Java, .Net, XML, UML, HTML.

Databases: Oracle, MS SQL Server, MS-Access

Operating Systems: Windows Family, Familiar with UNIX and LINU

RDBMS and Databases: SQL Server, Sybase MS Access

PROFESSIONAL EXPERIENCE

Confidential, Minneapolis, MN

Sr. Business Analyst /QA

Responsibilities:

• Worked with Delegates/vendors for the entire project of ICD 10 in Confidential . Dealt with internal and external representatives to capture requirements.
• Created Test cases using excel sheet and implemented the test cases in the test environment.
• Create and execute revenue cycle medication Epic billing data and reports from decision support and billing systems.
• Analyzed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed
• Analyzed System Impact including MMIS Tables, Windows, Reports and Interfaces to external entities
• Claims Process validation - Identified Claims Matching Scenarios upon which millions of Claim records were matched daily based on Patient's Information
• Liaised with end users on system design challenges and preferences in relationship to clinical processes and procedures; presented these findings to application. Development team, making recommendations according to billing workflow and end user need
• Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA(Patient Protection and Affordable Care Act), Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
• Create various complex reports using Crystal Reports XI R2
• Used SQL extensively in command objects of Crystal reports
• Analyzed HIPAA 5010 impact on external Data Warehouse and data warehouse extract process and mapping of MMIS database and data warehouse.
• Analyzed MMIS system impact for Windows and Interfaces.
• Developing reports on SSRS on SQL Server (2008)
• Performed admin tasks related to users, groups, folders, and security using Crystal Management Console (CMC).
• Involved in the integration and implementation of SAP Business objects and SAP BODS with SAP BW and also prepared and presented POC
• Managed the IFS reporting project from initiation to closing and was responsible to openly communicate results, reports and mitigate risks with the management.
• Using SSRS creating well-formed reports and web-based reports for health related applications and transactions.
• Researched data using SQL queries to capture and analyze back end system. Mapped the ICD 9 codes to the corresponding ICD 10 Procedure and Diagnostic codes.
• Tracked all the report, files and extracts exchanged between Vendors. Identified the location, purpose and requirement change after the ICD 10 updates are performed on the data.
• Captured the requirements for ICD 10 changes in the EDI 837 P&I X12 file.
• Used the companion guide and coordinated with the internal and external teams to capture detail loops and segment for the ICD 10 updates.
• Analyzed defects and issues using Microsoft Access Database as the front end system for Disease Management/Customer service team.
• Responsible for writing test cases and implementing them for the Business team.
• Gathered Reconciliation requirement and created Business Object Report spec for the internal Disease Management team.
• Configured Archive Export and Documentum Export modules to export content from Captiva to SAP and Documentum respectively
• Co-ordinated with test leads of various projects to make sue relevant defects were logged in and fixed bythe development team. Updated BRD's based on the defects identified by the Team.

Environment: Waterfall, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL.

Confidential, Worcester, MA

Business Analyst

Responsibilities:

• Analyzed the Plan Data Database using SQL Server. Surveyed and examined the current documentation.
• Gathered and documentedbusinessrequirements from SMEs, user groups and vendors via workshops, interviews and JAD sessions.
• Co-coordinating with the team to analyze the 834, 835 and 820 EDI Transactions for dual eligibility Project (FTC).
• Participated in testing of Orion Rhapsody Route to receive and process HL7 ORU R01 Version 2.5.1 messages to Websurv
• Involved in the testing of web portal of New MMIS system.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Generate reports with parameters, sub reports, cross tabs, charts using Crystal Reports
• Created Crystal Reports for different teams and groups in the organization to fulfill their business needs.
• Designed and developed the process for extracting, transforming, and loading data using the SAP Business Objects Data Services into SAP BW Data targets.
• Transformed the data to suit to business needs. Verified and improved the quality of your source data
• Scheduled reports to go to users directly, to share drives, etc. using Crystal Management Console and SAP BO CMC.
• Worked as a primary point of contact / liaison between Project Sponsors, Business Managers and Dev Team and Super Users from analyze to go-live phase in IFS implementation.
• Prepared the Functional requirement for the automation of 834 and 820.
• Analyzed the level of HIPPA Validations for the EDI transactions. Worked with the Solution architect on the approach to correct the current errors in the HIPPA validation.
• Using Process flows and Use Case diagrams to demonstrate AS IS and TO BE state.
• Worked in close collaboration withthe Project Manage and IT team.
• Created and gathered requirements for the Vendor. Helped PaySpan to create Data Mapping document for the EFT, 835 and Remittance Advise sheet.
• Gathered and documented requirements for EFT Project for PaySpan (Third Party Vendor).
• Coordinating with the QA team to create UAT test cases.
• Participated on cross-functional teams developing new or enhanced systems processes, procedures and policies.
• Provided project status reporting, updating of project information, effort & resource estimating.
• Effectively established and maintained working relationships with peers and constituents.
• Produced various artifacts Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• As a point person responsible for resolving business rules/conflict resolution for the development team.

Environment: Waterfall, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL.

Confidential, Austin, TX

Business Analyst/System Analyst

Responsibilities:

• Gained understanding of HIPAA 4010 versus 5010 and ICD-9 versus new ICD-10 code sets.
• Studied and analyzed the information provided by the CMS (Centers for Medicare & Medicaid Services).
• PreparedBusinessrequirement document (BRD) using Rational RequisitePro.
• Performed gap analysis for Upgradation.
• Worked on EDI transactions 276 (claim inquiry), 277 (claim response), 837 (Institutional and Professional claims) and 834 (enrollment).
• Went through the companion guide of the organization to understand the 837 and 834 segments used by the organization to identify the ones that need to be changed.
• Worked with the SMEs to convey the modifications that need to be made and the processes and systems affected by the same.
• Responsible for the mainframes that receive the HL-7 message in pre-approved format from the middleware as disclosed in the documentation.
• Worked extensively on migrating ad-hoc reports from SSRS2005 to SSRS 2008 using TFSserver
• Extensively used SQL queries to retrieve data for testing and analytics.
• Interpreted the ICD-9 to ICD-10 and reverse translation logic; fully understanding the GEM (General Equivalence Mappings) for ICD-10 CM and ICD-10 PCS.
• Understood complete claims processing cycle from the payer/provider perspective and the processes impacted by the conversion to ICD-10.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS
• Developing reports on SSRS on SQL Server (2008
• ) Using SSRS creating well-formed reports and web-based reports for financial applications and transactions
• Performed impact assessment for complete application inventory using Microfocus - a tool for impact analysis and application remediation; worked with the business team to identify business challenges, risks, opportunities and corresponding mitigations.
• Assisted the development team with the design and implementation of the ICD-9 to ICD-10 GEM crosswalk tool.
• Executed manual test cases to confirm the logic was implemented as desired.
• Participated in weekly meetings and walkthrough's for project updates to detect bottlenecks and devised plans to handle the bottlenecks.
• Facilitated the overall management of the project by collaborating with the team, providing weekly status reports and delivering presentations.
• Analyzed ICD-10 project readiness and recommended best practices for ICD-10 transition based on research conducted.
• Worked with the team to create a project road map/blueprint ensuring effective remediation of all applications that participate in the ICD-10 transactions

Environment: COBOL, GEM, MS Visio, Rational Rose, MS Office, SQL, Oracle, PowerPoint, MS Word, MS Excel, SQL, PL/SQL, ETL, ERWIN, UNIX, Windows

Confidential, Madison, WI

Business Analyst

Responsibilities:

• Prepared specifications for enhancements to the existing application by using existing legacy system documentation and procedures.
• Interacted extensively with End users in Underwriting, Claims Processing teams and Subject Matter Experts (SME's) in order to obtain the business needs and requirements.
• Organized, Facilitated and managed meeting sessions with major stakeholders and users in order to review business requirements.
• PreparedBusinessrequirement document (BRD) using Rational RequisitePro.
• Analyzed the business requirements and designed work flows in order to communicate to the major stakeholders how the system would be realized in the implementation phase.
• Migrated reports from version 10 to version 2008 of Crystal reports.
• Created reports using Crystal Reports with Standard, Summary, Cross Tabs, SQL, Command Objects, Selection Criteria, grouping, sub reports etc
• Interacted extensively with technical and development teams in order to ensure clear understanding of expected functionality, process flows and navigational flows of the new application.
• Assisted in EMR system implementation to enhance full two-way interoperability between Insurance Company and Physicians. Optimized training documentation prior to go-live.
• Documented system work flows and executed EMR training plans for staff that led to significant increase in EMR usage from 35% to 80%.
• Work with IT Development and QA staff to improve and customize the EMR application.
• Defined test cases, created test scripts and interacted with QA / development teams in identifying and resolving errors and in User Acceptance Testing (UAT).
• Actively participated in high level meetings with users and stakeholders to identify problems areas, resolve issues and improve the process in order to ensure an accurate and stable solution.
• Implemented the Rational Unified Process (RUP) to implement iterative SDLC.
• Developed RUP Analysis Model that included entity classes, use case diagrams, sequence diagrams in order to provide an accurate view of the requirements.
• Followed the Standard Operating Procedure (SOPs) of the company in documenting Test Plans, Test Cases and Test Procedures using Business requirements document and Functional requirements document of the system.
• Managed project progress by measuring against milestones, managed resource allocation, tracked project activities, resolved bottlenecks, published status reports and recommended actions.

Environment: MS Visio, Rational Rose, MS Office, SQL, Oracle, PowerPoint, MS Word, MS Excel, UNIX, Window

Confidential

Business Analyst

Responsibilities:

• Involved in requirement gathering, conducting requirement review meetings and working with other crossfunctionalteams to maintaining the project plan
• Gap Analysisof business requirements, generated workflow process,flow chartsand relevantartifacts.
• Defined and documented thevisionandscopeof the project.
• DevelopedProcess Modeland detailed Business Policies.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Performed manual testing on different modules of the application.
• DevelopedTest Matrixto give a better view of testing effort.
• Verified that the data outputs and transformations between systems remain true and not compromised as systems are bundled together.
• Participated in various meetings and discussed Enhancement and Modification Request issues.
• Attended weekly meeting to discuss progress and modification to test plans due to change in business requirements.

Environment: Microsoft Office suite, Rational Requisite Pro, Rational Rose, Microsoft Visio, Clear Case, UML, Quality Center, Oracle, JAVA