SUMMARY

• 7+ years of experience in business process analysis, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare, Insurance and Service Industry Sectors.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Expertise in Business Process Modeling, Business Process Re - design and in designing Process Architecture
• 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),HITECH compliance, Compliance issues, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837(P,I,D)/ 834/270/271/277/277 CA/276/997/999(X12Standards) processes of Medical Claims Industry from the Provider/Payer side
• Exposed to using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement methodology
• Strong experience with different project methodologies including Agile, Scrum Methodology, SDLC, RUP
• Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML), Object Modeling Technique (OMT) and Object Oriented Analysis (OOA).
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation (SOX), valuation review process and technology, strategic sourcing, metrics and benchmarking
• Experienced with BI Reporting Tools, Databases like SQL, Oracle.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Defining Test Cases, analyzing bugs, interaction with team members in fixing errors and User Acceptance Testing (UAT)

TECHNICAL SKILLS

Project Management: MS-Project2010, MS-SharePoint

Project Methodologies: Agile, Rational Unified Process (RUP), Waterfall

Process/Modules: Rational Rose, Requisite Pro, MS Visio

Databases: MS access, SQL Server, Oracle

Defect tracking tool: Quality Center, Clear Quest

Quality Assurance: Software Application Testing Life Cycle

Business Applications: Microsoft Office Suite, MS VISIO, MS Project, SharePoint

Quality Management: HIPAA, CMM, CMMI

Testing/Tracking Tools: HP Quality Center

Operating systems: Windows 98/ 2000/ NT/ XP

Office Tools: Microsoft Office, SharePoint

Languages: SQL, C, C++

PROFESSIONAL EXPERIENCE

Confidential, Dallas, TX

Business Analyst

Responsibilities:

• Facilitated requirements gathering sessions with the business unit managers and subject matter experts to document requirements.
• Documented the work flow using the flow charts for the application to be accessed by different types of Business Users.
• Documented the user Stories, Functional Specifications Documents and also Designed Data Flow Diagrams using MS-Visio.
• Followed Agile methodology, conducted SCRUM meetings to track, optimize and tailor features to customer needs.
• Published detailed guide describing data file content and structure for business partners; created quick reference guide for HIPAA EDI ASC X12 834, 835 and 837 transaction set for Medicaid enrollment, and claims and remittance
• Coordinated testing for contract set-up, enrollment and claims processing for four new managed care contracts for Medicaid mental and physical health providers.
• Involved in intensive system level testing of analyzing the HL-7 messages coming out and in of EPIC Bridges.
• Responsible for the mainframes that receive the HL-7 message in pre-approved format from the middleware as disclosed in the documentation.
• Researched and documented data variances reported by managed care contractors
• Reverse engineered processes where no documentation for system existed.
• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model
• Assisted Project manager to create project timelines, milestones, resource planning etc.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
• Reviewed extensive SQL Queries with complex multi-table joins and nested queries.
• Involved in reviewing complex SQL queries, views, functions and stored procedures and spotting issues before/during code migration.
• Rigorously tested SQL’s implementation of existing code.
• Participated in design of the Master Test Plan Documents, Test Cases, Test Plan.
• Participated in User Acceptance Testing with Business Users.
• Co-ordinated with the Development Team and Testing team to track the Defects and Resolution.
• Participated in Analysis of High Priority issues and risks as part of Risk Assessment.
• Designed the Test Metrics Documents for tracking the Status and Compliance of the Application.
• Performed Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Participated in the walkthroughs and meetings specifically for Assessments and The report Generation.
• Created the report from the databases using Crystal Reports.
• Coordinate with Development and Business team to develop high level Business and Technical documents.
• Worked with the clients on the verification process for the requirement phase documents
• Implemented Agile Framework throughout the software Development Life Cycle (SDLC).

Environment: MS Office suite, MS Visio, SQL, Rational Unified Process (RUP), HP-Quality Center, Rational Suite, Windows XP, SharePoint.

Confidential, Dallas,TX

Business Analyst

Responsibilities:

• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules.
• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Worked with the SMEs (Subject Matter Experts), IT managers, software architects to identify the key changes pertaining to HIPAA, and participated in Health Management to communicate effectively with them.
• Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
• Gathered the Requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act (PPACA).
• Worked on billing system a cash management module and enhanced the encrypting standards that are required for the application.
• Followed a systematic approach to eliciting, organizing, and documenting requirements of the system.
• Reviewed the Joint Requirement Documents (JRD) with the cross functional team to analyze the High Level Requirements.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Planned and documented procedures for data processing and prepared data flow diagrams for the application.
• Evaluating various open source architecture framework in the architecture framework to come up with the architecture roadmap for the client.
• Expertise with supply chain strategies/vendor manufacturing process methods to determine level of procurement and strategic sourcing strategies/plans and worked with vendors/peers to determine lead times, schedules and cycle counts, established requirements needs.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Prepared and documented System Requirements and workflows for the Content Management Application tool.
• 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)
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Experience of working with Medicare and Medicaid insurance data, Claims Processing, Insurance Pricing and Claim Adjudication.
• Strong Experience in FEP (Federal Employment Program) and CDA (Clinical Development Analytics). Healthcare Domain Knowledge with SQL knowledge (in Oracle environment) and 5010, ICD-10 experience.
• Participated in 1CD 9 to ICD 10codes mapping sessions as well as status meetings and provided comments and suggestions on challenges.
• Gathered requirements on Trading Partner Registration and certification. Verified Trading Partner configuration and the profiles.
• Mentored business analysts in methodology for defining ICD-10 mapping processes and documenting business requirements.
• Developed additional processes specifically designed to handle Benefits Administration.
• Participated in changing of 4 digit numeric codes of ICD-9 to Alpha-numeric codes in ICD-10.
• Created an enterprise workflow application based on CRUD rules for Customer Data that would allow for future integration of data infrastructure across various business areas into a single User Interface.
• 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.
• Involved in the design of the Automation framework.
• Performed data analysis by using SQL queries
• Designed the Master Test Plan, Test Plans,Test Cases and also Test Metrics Documents.
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Designed and developed project document templates based on SDLC methodology
• Designed workflows and allocated permissions within SharePoint.
• Performed Unit Testing and User Acceptance testing (UAT) and documented detailed results.
• Provided input (scope, goals, risks, constraints, timelines and interfaces) to PM for project planning and control.

Environment: Microsoft SharePoint, MS Visio, MS Office, HP Quality Center, Oracle, AGILE methodology, DB2

Confidential

Business Analyst

Responsibilities:

• Worked with Clinical Services Dept. to gather business requirements
• Created workflow documentation to give better idea to the healthcare clients.
• Analyzed corporate healthcare business processes to develop customized solutions.
• Worked as a functional and technical analyst to support healthcare client\'s system.
• Designed solutions for proprietary patient
• Documented AS-IS and TO-BE processes.
• Developed User Stories, Use Cases and Test Scenarios
• Experienced with Agile Methodology
• Conducted the JAD Sessions with stakeholders and developers to have a clear picture of a project.
• Wrote SQL scripts for creating performance evaluation reports.
• Developed test cases and test plans on the basis of requirements and also did manual testing of the functionality of the application to ensure that the application is able to handle a lot of data.
• Maintained Traceability Matrix throughout the project.

Environment: SQL, MS Word, Excel, MMIS, ACCESS, File Viewer, Web client, Clear Quest, Agile, GEM, MS Visio, SharePoint.

Confidential

Business Analyst

Responsibilities:

• Gathered requirements and communicated the business and technical requirements to the developers
• Worked closely with project stake holders, SME&; s& staff to understand the requirements & specification for new application along with reengineering the existing application.
• Performed gap analysis, SWOT analysis and risk analysis
• Developed and maintained operational & technical flows using Visio and PowerPoint.
• Involved in writing Use Cases and Test Cases based on the Business narratives, Functional requirement specs (FRS), and Design specs.
• Redesigned the Product Pricing business process for flexible and accurate pricing of healthcare Products.
• Co-oordinated the testing efforts.
• Provided on call coverage and support to business operations.

Environment: Microsoft SQL server, Microsoft Office, Data migration-Export & Import, Rational Suite, RUP, Requisition Pro, Visio, HP Quality center, Clear case