SUMMARY:

• Over 6 years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Extensive experience in documentation of business requirements and system functional specifications, including BRD, FRD, and FSD.
• Hands on experience working with HIPPA Transactions such as 837, 834, 278, 270 and 271.
• Good Working Knowledge of HIPAA Regulations and Claims Processing.
• Facilitated sessions with the senior management to identify business flows and determine whether any current or proposed systems are in compliance with HIPAA guidelines.
• Development of standard documentation package Business, functional, technical Requirement Specification, Design, Operations, and Quality Test Plans .
• Created and modified SQL Queries for new reports and to address changing business rules.
• Designed and implemented basic SQL queries for QA Testing and Report / Data Validation.
• Used SQL to query the database and performed data analysis.
• Interacted with the Subject Matter Experts SMEs and stakeholders, gathering business requirements to get a better understanding of client's business processes.
• Analyzed health plan requirements and then contributed further defining the plan requirements with their Project Manager. Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements.
• Extensive knowledge of Health Insurance Portability and Accountability Act HIPPA standards, Electronic Data Interchange EDI and implementation of HIPPA code sets, ICD-9, ICD-10.
• Strong experience in Data Warehouse Concepts, ETL.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Created design documents like data flow diagrams, process flow charts using MS VISIO and UML.
• Highly motivated, organized and target oriented team player who enjoys working with multi-functional team towards a common goal.

Technical Skills:

• Operating System : Windows 95/98, NT, 2000, XP, Vista
• Languages : SQL, SAS
• Databases : Teradata, MS Access
• Business Tools : MS Visio, MS Project, MS Access, MS Office Suite.
• Business Skills : Business Definition Requirements, Business Process Analysis, Gap Analysis, Use Case Modeling Analysis, Business Environment and Market Research Analysis.
• Methodologies : RUP Business/Data Modeling
• Packages : MS Office Suite.

Professional Experience:

Sr.Business Analyst

CONFIDENTIAL . is one of the largest health benefits companies in the CONFIDENTIAL . Through its networks nationwide, the company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. The company wanted us to develop a data warehouse which would facilitate ease in reporting.

Responsibilities:

• Reported to National Medical Director Medicaid operations.
• Produced Ad hoc reports by extracting data Legacy WellPoint from enterprise data warehouse repository system using Teradata SQL and SAS EG.
• Worked extensively in Analysis and financial reporting to Business Owners.
• Experience in designing and developing reports using MS Access, MS Excel and Data View web part.
• Tested for eligibility, Gender mismatch, clean claim edits, Membership Edits, Medicare, New born and Behavioral claims.
• Prepared Business Requirements Document BRD by gathering requirements from all the stakeholders translated BRD to Functional Specifications Document FSD and created prototypes.
• Developed Use Cases as well as flow charts based on the proposed enhancement for the system.
• Followed a systematic approach to eliciting, organizing, and documenting requirements of the system.
• Worked on data modeling and produced data mapping and data definition documentation.
• Created and modified SQL Queries for new reports and to address changing business rules.
• Analyzed health plan requirements and then contributed further defining the plan requirements with their Project Manager.
• Designed and implemented basic SQL queries for QA Testing and Report / Data Validation.
• Used SQL to query the database and performed data analysis.
• Development of standard documentation package Business, functional, technical Requirement Specification, Design, Operations, and Quality Test Plans .
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data .
• Professional experience in Business Analysis, Software Development Life Cycle: System Analysis, Design, Development, Testing, and Implementation on Business Systems.
• Performed analysis of existing SQL Server databases and reports in order to modify existing and create new Crystal Reports reports.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Responsible for documentation of business requirements and system functional specifications, including BRD, FRD, and FSD.
• Documented the Traceability Matrix for tracing the Test Cases and requirements related to them.
• SQL Querying Implemented projects that were based around workflow solutions that were specified by the customer.
• Expertise in development of High level design, Conceptual design, Logical and Physical design for Database, Data warehousing and many Distributed IT systems.
• Extensively facilitated meetings/conference calls with stakeholders project managers, developers, QA Analysts and other end users based onsite/offshore to deal with business and technical issues and resolving the issues.
• Strong relational database acumen including mid-level to advanced usage of SQL queries to build re-usable and user-friendly SQL statements liaison between system and EDW architects to design efficient table and database structures to accurately construct functional requirements.
• Foster effective communication with and between various internal and external entities utilizing excellent conflict resolution skills patience, listening, understanding.
• Trained and implemented Lean System Development Life Cycle SDLC and RUP methodologies from Initiation to deployment
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Responsibilities include Business Analysis by using the iterative software development life cycle principles of RUP.
• Good knowledge of Health Insurance Plans Medicare Part A, B, C and D , managed care concepts Medicaid and Medicare and experienced in determining themembership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding.

Environment: Windows 7/ XP Professional, Oracle9i, MS Access, MS Excel, MS Visio, MS Office, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case, Rational Clear Quest, MS Office suite, MS Visio.

CONFIDENTIAL

Business Analyst

CONFIDENTIAL is a leading health care company, serving more than 75 million people worldwide. As a leader in the health benefits and services industry, UHG has six businesses UnitedHealth care Employer IndividualCONFIDENTIAL Optum Health, OptumInsight, and OptumRx that offer exceptional service, broad capabilities and enduring value in creating a modern health care system. . I have worked with various Business Areas like Enrollment, Claims, Finance, Providers, and Benefits Admin. My project involved gathering Business Requirements for the Claims Business Area and updating EDI Transactions like EDI 837, 835 and 834 with the HIPAA 5010 Changes. The project involved work in the lines of business of the insurance industry including marketing, policy writing, claims processing, Accounting and Financial reporting.

Responsibilities:

• Involved in the full CONFIDENTIALcompliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Worked with CONFIDENTIALand regulations to draft business rules and claim processes
• Researched EDI claims and claims adjustments data to determine root causes of data errors.
• Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits including Medicare .
• Responsible for healthcare Insurance Claims that were scanned and processed through OCR Software , also document Retrieval and storage was imperative with healthcare insurance processing.
• Documented Medicare claims processing.
• Incorporated Rational Unified Process RUP to create Business Requirement Document BRD Specifications using MS Visio and MS Word.
• Elicit business requirements, translating requirements and user expectations into documented business and functional specifications.
• Elicit and document client user requirements to meet business objectives.
• Review documentation to determine if any updates need to be made to existing databases/process for billing, enrollment or reconcillation.
• 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.
• Extensive experience in implementing Sure scripts, Patient Education, Medical Necessity, and other Medicare incentives.
• Expert in ICD 9 10 Conversion Analysis. Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers.
• Prepared Functional Specification Documentation FSD and communicated these to the stakeholders.
• Responsible for creating a business process and workflow documentation using BPMN standards.
• Used SQL Profiler and Query Analyzer to optimize DTS package queries and stored Procedures.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Used the DataStage Designer to develop processes for extracting, cleansing, transforms, integrating and loading data into data warehouse database.
• Created SQL reports, data extraction and data loading scripts for different databases and Schemas.
• Gathered and documented functional requirements for testing and verification of HIPAA Administrative Simplification X12 standards, 837 Institutional and Professional HIPAA standard transactions and EDI messages 837 Healthcare encounter claim and coordination of benefits COB - claim payment and remittance advice 835.
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Designed and developed project document templates based on SDLC methodology.

Environment: Windows XP Professional, MS Office, UAT, Java, .Net, Rational Enterprise Suite Rose, RequisitePro, ClearCase, ClearQuest , MS Office, Oracle, DB2, Sybase, SQL Server Reports, WinRunner, LoadRunner, Quick TestPro.

CONFIDENTIAL

Business Systems Analyst

CONFIDENTIAL based Medicaid Management Information System MMIS was developed for the CONFIDENTIAL it was used to keeps track of Healthcare transactions like Eligibility Request/ Response, Request and Response for Claims Status, Prior Authorization, Claims Vision and Claims Payment.. Proactively created project plans to manage changes in scope, identified potential risks, and devised contingency plans.

Responsibilities:

• Facilitated collection of functional requirements from system users, and prepared business and technical requirement specification documents.
• Interacted with the Subject Matter Experts SMEs and stakeholders, gathering business requirements to get a better understanding of client's business processes.
• Used UML, for gathering requirements, created Use Case Diagrams, and Use Case Specification document USD .
• Authored Business Requirements Document BRD with project teams. Extracted, discussed, and refined business requirements from business users and SME's.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Used SDLC System Development Life Cycle methodologies like the RUP and the waterfall.
• Gather requirements by conducting meetings and brainstorming sessions with end users and SME and document them using Requisite Pro - the documentation tool offered by Rational.
• Played an active role in gathering, analyzing, and writing business requirements using RequisitePro.
• Researched, defined and deploy BI improvement opportunities and streamline the business intelligence processes.
• Designed and implemented basic SQL queries for QA Testing and Report / Data Validation.
• Queried database using SQL for backend testing.
• Prepared Business Object / Business Process Models BPM that included modeling of all the activities of business from conceptual to procedural level.
• Involved in design and development of the complete Decision Support System to be used to create reports using Business Objects.
• Responsible for providing BI support and ensuring high levels of availability in the Business Intelligence environment.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System MMIS .
• Validated the following: 837 Health Care Claims or Encounters , 835 Health Care Claims payment/ Remittance , 270/271 Eligibility request/Response , 834 Enrollment/Dis-enrollment to a health plan .
• Developed and maintain information and documentation related to developing and modifying business processes and systems.
• Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and Use Case Narrative using the UML Unified Modeling Language methodologies.
• Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using Rational tools.
• Established RUP Rational Unified Process methodology and provided assistance in developing Use cases and project plans.

Environment: Rational Rose and Requisite Pro, MS Visio, .Net, MS Project, UML, XML, Windows XP, HTML, J2EE JSP1.2 , XML, XSL, XSLT, HTML, Oracle .

CONFIDENTIAL

Business Analyst

CONFIDENTIAL is a publicly traded American company that provides Revenue Cycle management, Accountable care management, Spend and clinical Resource Management, Advisory Solutions, Payor Solutions software. CONFIDENTIAL a healthcare performance improvement company focused on helping providers realize financial and operational gains so that they can sustainably serve the needs of their community.

Responsibilities:

• Gathered and Analyzed the requirements and converted them into Business Requirement Specifications BRS and Functional Requirement Specifications FRS for the designers and developers and QA Team to understand them as per their perspective.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams.
• Created As-Is Business Models to understand the existing claim settlement process flow through interacting with SMEs, underwriters and Finance department.
• Got exposure of EDI, Web Portal and System documentation.
• Involved in requirements gathering sessions with Business Analysts and Architects to understand requirements in terms of business change.
• Involved in generation and execution of SQL queries.
• Gathered and analyzed the requirements and converted them into Business Requirement Specifications BRS and Functional Requirement Specifications FRS for the designers and developers and QA Team to understand them as per their perspective.
• Responsible for identifying and maintaining a clear and measurable software development process that is deployable throughout the enterprise using SDLC.
• Created high level turnover documents like System Maintenance and Technical Documents at the client side for the production support team.
• Validated data at the backend to ensure that all the claims related data has been loaded to the corresponding data sets in the backend and the pricing for these claims is done as per the standards.
• Analyzed the results, generated reports and tracked the defects using Quality Center.
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
• Responsible to meet the information demands of business users by delivering timely, accurate, meaningful and standardized data and reporting.
• Used SQL statements for Back-end testing.
• Created and maintained the Test and Traceability Matrix, Use Cases, Actor Table, Activity Diagram, State Diagram, Context and Level Diagram, Data Models like ERD and Data Flow Diagrams, Glossary, Data Dictionary, Metadata etc.
• Conducted System, Integrated and Regression testing to the application using Business, Functional, User Acceptance and Usability testing.
• Prepared test data in HIPAA compliant format for both inbound and outbound healthcare EDI transactions.
• Actively participated in all phases of testing lifecycle Design, Planning, Development, UAT and user manual .

Environment: Windows Xp, MS Excel, MS Visio, MS Project, SharePoint, UML, SQL Server, SDLC/Agile, Quality Center,