SUMMARY

• 6 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.
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile& Waterfall life cycle
• 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
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Knowledge on HP Interchange healthcare Platform.
• 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 healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Knowledge of Electronic Medical Record ( EMR ) and Electronic Health Record ( HER)
• Knowledge in Health Care Reform and Patient Protection and Affordable Care Act (PPACA)
• Experience with HIPAA compliance (4010 & 5010) and Healthcare 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

Reporting Tools: Business Objects

PROFESSIONAL EXPERIENCE

Confidential, Worcester, MA

Business Analyst

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

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).
• 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.
• Worked with internal Business team and State of MA to correctly update the MMIS ID’s of the member’s in FCHP database.
• Worked with State of MA and clearing house to send and receive Exception reports (Invalid MMIS Id’s) in specific format from and to the State of MA.
• Helped the internal FCHP team with the new Interchange inSight reporting Servicing.
• 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.

Confidential, Eagan, MN

Sr. Business Analyst

Environment: M2, Agile, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL, Trizetto Facets, MMIS

Responsibilities:

• Gathered and documentedbusinessrequirements from SMEs, user groups and vendors via workshops, interviews and JAD sessions.
• Prepared a comprehensive Functional Requirements Document and Supplementary Specification Document (nonfunctional) from the gathered requirements.
• Involved in writing USE cases and prepared the Business Requirements Documents for various requirements collected from the business users. Used MS Visio and UML for generating class diagrams and activity diagrams.
• Worked in close collaboration withthe Project Manager, NASCO team andbusinessusers to gather analyze and document the functional requirements for the project.
• Facilitated and managed meeting sessions withcommitteeof SME's from variousbusinessareas including Benefits Administration, Health Claims Group, HIPAA Administration, Health Policy and Program Evaluation Team and Data Management Group.
• Worked on several functional areas of MMIS claims processing unit and EDI for transfer of data between organizations by electronic means.
• Created Functional specifications for the Provider tracks with their changed Reimbursement and Administration in the Medicare and Medicaid program. Worked on PCC and Referrals Benefit tiring with NASCO team.
• Created and gathered requirements for the Vendor. Helped NASCO to create their CSD(Conceptual Structural Design ).
• Created Data Mapping document,
• Gathered and documented requirements for CCS Benefit track for health insurance carriers.
• Participated in entering, tracking system defects in Rational Clear quest.
• Submitted change requests and worked with change request records in Clear quest.
• Involved in Configuration Management, Requirement management and analysis.
• Provide technical and procedural support for User Acceptance Testing (UAT).
• Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management

Confidential, Albany, NY

Business Analyst

Environment: Mercury Test Director 8.0, PVCS Tracker, Oracle 9i, Java/J2EE, RequisitePro, ClearCase, ClearQuest, MS Project.

Responsibilities:

• Helped create Level I and Level II specifications including VISIO data and program flow charts utilizing Gentran Translator’s capabilities and limitations. These techno-commercial documents were presented to the Confidential for their approval for claims (837I/837P/837D), Service Review Request and Response or Prior Authorizations (278), Eligibility Verifications (270/271) and Claim Status Request/Notification (276/277). Outbound batch transactions included Claim Payment Advice (835).
• Researched the then current application, various compliance issues, providing insights to the architecture group, Security group, and resource management group for effective budgeting, bridging with the Translator vendor’s technical group and converting these semantics to the eMedNY application.
• Helped alleviate the problem of insufficient test data, inaccurate test files by creating large and complex, compliant and non-compliant test files with positive and negative test conditions. Helped achieve conformance by doing unit testing, system testing, regression testing, volume testing, end-to-end testing, user acceptance testing (UAT), Trading Partner enablement by first promulgating test cases and test scenarios and creating a test result documentation methodology that supports a stringent pedantic testing but also eventually supports a realistic production environment.
• Create customized Implementation Guides using the SpecBuilder 5.1 module of EDIFECS software for 837 Professional, 837 Institutional, 837 Dental, 835 Remittance Advice, 276/277 Claim Status/Response transactions /271 and all NCPDP transactions like B1, B2, B3, B4, E1, P1, P2, P3, P4.
• Involved in Validating the System in Accordance with 21CFR Part 11.
• Created use case narratives to record Subscription business rules.
• Analyzed the business rules for the international user subscription and impact of localization.
• Implemented SDLC, which included requirements specifications, design, analysis and testing. Followed RUP methodology with Agile/Extreme Programming and using Rational Test Suite for various phases of RUP.
• Provided technical Expertise on the use of Rational Clear Case and Requisite pro, which were used for Data archiving and Requirements Management.
• Defect Tracking with Clear Quest, Configuration Management with Clear Case.
• Involved in preparing test plan and test cases based of functional requirements using Rational Test Manager.
• Work experience in maintaining data marts dealing with ETL (extraction, transformation, load) using Oracle and Informatica.
• Dealt with data mapping issues between various source systems and staging area and data-marts.
• Worked with Business users to come up with Reporting Requirements. Reports were developed in Cognos.
• 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.
• As member of system architecture team designed and reviewed user interface.
• Developed Business case and assessed the ROI.

Confidential, Bethesda, MD

Business Analyst

Environment: IDX, MS Visio, MS Office, CMMI, Rational Rose, Requisite Pro, SQL, Oracle, FACETS 4.51

Responsibilities:

• GatherBusinessRequirements from theSubject Matter Experts (SMEs)and document the requirements in theBRD. Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by theBusinessOwners.
• Perform Analysis ofICD 9 Procedure and Diagnosis Codesin accordance withICD 10 CM and ICD 10 PCS Conversion Compliances.
• Organizemeetings and ledJAD sessionsto ensure legal and compliance deadlines ofCMS(Centers for Medicare and Medicaid Services) are met.
• HIPAA Conversion Analysis - Involved in the documentation of HIPAA 5010 changes toEDI 837, 834, 835, 276, 277Transactions.
• Formulatesystem design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes likeHIPAA/ EDIformats and accredited standards like ANSI
• Configured theClaim ProcessinginFACETS 4.51. Good knowledge about the workflow and backendTables in Claim Processing.
• Worked in Claims processing systemforPharmacy Benefit Management along with review, design and reconfigure of theFACETSin functional areas like Membership, Claims, provider, Enrollment and Service.
• PerformGAP analysis toassess“AS IS”and“TO BE”scenarios.
• Createprocess flows diagramsfor all“AsIs” and“To Be”scenarios using MS Visio.
• Involved in BusinessProcess Redesign and its documentation
• Work with BusinessOwners ofIDX, the claimsadjudication system,and documented updates and enhancements to the application.
• Effectively elaborated theCurrent processand gave a clear picture of the proposed process for the projects in the organization. Work aggressively towards timely completion of High Priority Tasks.
• Vendor Management - Work as a facilitator for Testing Efforts and New Requirements between theHealthcareCompany and its various Vendors.
• Work with IT to resolve issues and clarifyBusinessRequirements from theBusinessOwners.
• Maintained theTraceability Matrix tableto uniquely trace the identifiedbusinessrequirements to general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked
• Document theUAT Planfor the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Worked with theUAT and QAteams to conduct an assessment and determine how effective UAT and QA guidelines can help the company achieve timely completion of projects.

Confidential, Buffalo, NY

Business Analyst

Responsibilities:

• Primary responsibilities includedGapanalysis, Data analysis, interpretation and leadershipof resources to meet business needs; providing effectivetechnology solutions.
• Gathered requirements from the SMEs (Subject Matter Expert), preparedBRD (Business Requirement Documents)using standard document templates, and constantly communicated risks/contingencies to project managers, consulting with technical development staff to clarify business requirements.
• Worked inFacets Reconfiguration Data Element Definition and Usage (Working) with valuesand completed configuringFACETSApplications like Related Entity, Parent Group, Group, Subgroup, and Member/Subscriber usingIVSTech Data Toolset.
• Analyzed dataand created reports usingT-SQLqueries for all issued Action Items.
• DevelopedData MappingandCrosswalk.
• CompletedData Mappingfor Group and detailProduct analysisandreport writing.
• Participated in solving Billing issues from theFACETSProblem log forTrizetto team and Billing Entities.
• Performeddata validation, loading and unit testing.
• Participated inIBM Process Modeler (WebSphere Business Modeler)training and developedBusiness Process Modelfor different Business Processes followed by HealthNow includingE2E (End to End)Member Enrollment.
• DesignedFlow chart and process modelfor different department including business andHR.
• Extracting data frommainframe/DB2using SQL; data analysis and reporting for different department.
• Developed Business Process like setting up Group or Subgroup Billing Entity using Billing Profile and CHP enrollment in Visio.
• Documented and mapped the variousCPTandICD 9codes with incoming claim messages. Analyzed the impact of changes toICD 9codes on various sub-systems.
• Involved in analyzing the components for claims adjudication inITS.
• Involved in preparinguse casesand designed/documentedtest cases corresponding to the various scenarios that can occur in theITSsystems involving blue card members.
• Provided an analytical assessment of current business functions and solicit input for system requirements; including functional future state requirements.
• Collaborated withSBU’s (Strategic Business Units)and Core operations to communicate progress, resolve issues, and develop partnerships.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements withinFACETS.
• Tracked and reported change, incident, and risk management standards, processes, and HealthNow policies.
• Implemented methodology to acquire business requirements from organizational Subject Matter Experts, developers and user interface designers.
• FacilitatedFACETSrequirements andUse Case sessionswith SMEs.
• Conductedresearch, analyze dataand develop/recommend business solutions.
• Exposed to extensive experience levels and overall knowledge in the suite of Facets Applicationssuch as Accounting, Billing, Capitation/Risk, Membership, Provider, Eligibility, Group, Product, Enrollment, Provider, Claims, Correspondence and Letters, Facilities, Customer Service and Health Care Regulatory standards.
• Participated in “HealthNow Products: Planning for Success” program which included Traditional, PPO(Preferred Provider Organization), EPO(Exclusive Provider Organization), POS(Point of Service)and HMO (Health Maintenance Organization).
• Participated in “Life of a Claim” training, detail Claim process tour includedHIPAA compliance, electronic (EDI837,EDI835, etc.) and paperclaimprocessing (CMS 1500, UB04, ADA Claim form and Vision).
• Worked withPegadeveloper to document business rules and batch processing system forClaimsprocessing and also participated inPega’sEnd-to-EndSales POC presentation & Demo for (SPM).
• UsedPegato configure Sales Process Manager Framework (SPM) to address the HealthNow’s pain points and needs.
• Documented data source definition, source-to-target mapping, and logical structures for thedata warehouse/datamart.
• 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.