OBJECTIVE:

To analyze business needs and lead projects in the healthcare market and as well as Work on Technical Projects inclusive of EDI, HIPAA, Healthcare, Insurance Market, Software and Systems/Unit validation.

SKILLS:

• A result oriented individual with over 6 years of diversified experience in Finance, Insurance.
• Strong knowledge of the SDLC models such as Water Fall, Agile, and Spiral.
• Experience in creating and maintaining the Requirements definition documents that included Business requirements and Functional requirements.
• Knowledge of EMR/EHR, Patient Protection and Affordable Care Act PPACA .
• Experienced as a Facets Business Analyst in gathering the business requirements from the existing stored procedures, supporting the Interfaces and reports development in explaining the functional requirements, proposing technical solutions, supporting the unit testing and system integration testing with the functional flow.
• Skilled in developing Use Case diagrams, Sequence diagrams, State Chart diagrams, and Class diagrams.
• Experience in configuration of claims adjudication systems, i.e., Facets, QNXT.
• Expertise in Facets extension development, Facets Testing, Facets Interfacing.
• Familiarity with different aspects of Facets implementation lifecycle.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277/997 X12 Standards processes of Medical Claims Industry from the Provider/Payer side
• Knowledge of health information and health care services regulatory environment including HIPAA, Medicaid/Medicare, CCHIT, EDI and XML
• Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis compliance experience from, payers, providers and exchanges perspective, with primary focus on Coordination of benefits
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Provided analytical solution to the customers for Facets Production Issues
• Good Management, Execution and Documentation skills
• Experienced in reporting bugs using Test Director and Quality Center.
• Involved and tracking the defects using Quality Center
• Strong working experience with HIPPA Transactions
• Good working knowledge of major Operating Systems and tested applications developed in wide variety of environments viz., Windows 98/NT/2000, UNIX
• Experienced in creating Test Plans. Thorough hands on experience with designing test cases covering all test conditions and eliminating redundancy and duplications
• Experience in interacting with business analysts, developers, technical support and help them base line the requirement specifications
• Used MS Excel spread sheet, PowerPoint, MS Visio, MS Projects
• Performed Sanity, Smoke and Usability Testing

TECHNICAL SKILLS:

• Operating systems: Windows 2003 Server, Windows XP/2000, UNIX
• Testing tools: Quick Test Professional, SoapUI, JIRA
• Bug tracking tools: Quality Center, Rational Clear Quest, Test Director
• Front-end tools: MS Office, MS Project
• Languages: C, C , SQL, TSL, PL/SQL
• Web technologies: HTML, XML, E-Portal, IIS, Sun One Server, Microsoft Team Foundation Server, IBM WebSphere Portal
• Databases: Oracle, MS SQL Server

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Business/ Systems Analyst

I was involved in a project to re-engineer a suite of Medicaid management products and create a core application called Enterprise. My team was responsible for receiving, documenting, tracking and addressing the problems encountered by the customers of Flagship software product EPM Enterprise Practice Management while generating 837 Professional, Institutional, and Dental claims, Functional Acknowledgement 997, Claim Status Inquiry/Response 276/277 Unsolicited for their destination direct Payers or Clearinghouses such as Proxy Med, WebMD, Per Se, THIN, Via Track, NovaCare, McKesson, Champus-TriCare, Payer Path, Via Track, Access, etc. The product was also integrated with Trizetto's Facets application for Claims processing.

Responsibilities:

• 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
• Utilized Rational Unified Process RUP to configure and develop process, standards and procedures
• Met with report users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews group and one-on-one along with JAD sessions
• Involved in understanding the current business process, defining scope of the project along with position statement
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional requirement
• Developed and executed various Manual Testing Scenarios and neatly documented the process to perform Functional Testing.
• Participated in the management of testing project with the help of Quick Test Pro.
• Implemented automated COB processing of Medicare claims into Facets
• Validated business rules and all artifacts with users, got approval and sign off
• Followed Unified Modeling Language UML methodology using ReqisitePro and MS Visio to create/maintain Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams
• Executed Test Cases using positive and Negative data in Quality Center test lab and reported results and defects using QC defects tool.
• Participated in requirement walkthroughs and creation of test plan.
• Developed and executed test cases, test scenarios and followed-up defects using Test Director
• Developed automation test scripts for performing regression testing on the application using Quick Test Pro.
• Tested and delivered Inbound/Outbound Facets interfaces
• Involved in writing and executing test cases using MQC based on the requirements
• Performed Back-End testing
• Assisted Design Team in preparing SRS, Software Design Document SDD , User Interface Design, Application Architecture, Database Modeling.
• Helped in project testing efforts for doing integration tests, regression tests and user acceptance tests.
• Worked on Data mapping, logical data modeling and used SQL queries to filter data within the Oracle database tables
• Made sure that the systems complied with the rules of HIPAA and CFR Part 11
• Documented the dimensional models of ETL system
• Used SQL to test various reports and ETL load jobs in development, QA and production environment

Environment: MS Office Tools, Windows XP, MS Project, Quick Test Pro, RequisitePro, MS Visio, Clear Case, MS PowerPoint, Java, JSP, SQL,MS-Word, MS-Excel, Business Objects ,Oracle, Informatica 7.1, Facets

Confidential

Sr. Business/Systems Analyst

Confidential

• serves more than 5 million members in all 50 states across a full range of products and services including group and individual health insurance, Medicare and Medicaid programs, workers' compensation.
• Worked as a Business Analyst to analyze, document and map the 4010 to 5010 changes as a result of the HIPAA 5010 requirements for EDI Transactions. Was also involved in the Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10 Conversion for CM Diagnosis Codes and PCS Procedure Codes . Involved in Confidential
• tools for forward mapping of ICD 9 ICD 10 codes

Responsibilities:

• Employed Capability Maturity Model CMM to meet business operational needs
• Involved in claims submission and payment remittance retrievals by using ASCX12N 820 for the In- bound premium payments ASC x12N 834 for the Inbound Enrollment and Maintenance ASCX12 276/277 for the claims status enquiry and response and ASC X12 835 for the Health care Claim Payments
• Responsible for customer interface, requirements definition, general and detailed design, testing, maintenance and training programs and managed requirements using Rational Requisite Pro.
• Performed GAP analysis for ICD - 10 and EDI 5010 X12 Message Structure with the 4010 Structure.
• Developed End-to-End Business Process Flows for HIPAA 5010 EDI transactions including 834 Benefit Enrollment and Maintenance , 835 ERN-Electronic Remittance Notification and 837 Claims Submission Transactions.
• ICD 9 ICD 10 Conversion Project Worked in the analysis of the ICD 9 10 codes conversion Project. Expertise in GEM processes and concepts.
• Drug Card Project Worked in a project involving Miami Systems to create Drug Cards.
• Created Test File to be sent to the Drug Card Vendors for approval. Worked on a Paid without prejudice project for various States.
• User Acceptance Testing UAT Performed UAT tests using the MORAE Usability Testing Tool using the Observer and the Manager Mode.
• Testing - Developed Test Scripts using Test Director/Quality Center and coordinated with developers to quickly resolve the defects associated with them.
• Conducted JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions the performance of the application from various dimensions.
• Helped create the 'Business Glossary' to facilitate efficient understanding of the business process amongst the other teams.
• Assisted in creation of the Functional Design Document from the Business Requirements Document which was used as the reference by the development team while preparing the design and held the responsibility of the required data setup for unit testing
• Negotiated and managed multiple priorities, project plans, time frames and trade-offs while ensuring the clinical and administrative staff understood the final results of the projects, sharing detailed vision of cost-benefit analysis
• Writing Test Plans/Test Scenarios/Test Cases/Test Matrix.
• Used the Rational Unified process methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams using MS Visio
• Involved in writing and executing test cases using MQC based on the requirements
• Performed Back-End testing
• Assisted the development team during the second and third iteration using the RUP model
• Developed design Specification writing Test report s and documenting Test results
• Used RUP to create use cases, activity, class diagrams and workflow process diagrams
• Identified customer requirements besides reviewing test plans and documented the development of these plans
• Developed automation test scripts for performing regression testing on the application using Quick Test Pro
• Conducted interviews and workshops for soliciting customer requirements
• Performed Test execution and wrote and executed Test scenarios /Test Scripts
• Utilized technical flow charts, Network Diagrams and Gantt Charts to effectively map and manage critical paths and bottlenecks in conjunction with Project Tracking Reports and Project Data Sheets for Senior Management.
• Defect Tracking and Bug Reporting was performed using Quality Center

Environment: MS Office Tools, Windows XP,SQL, HTML, MS Project, RequisitePro, Oracle, MS Visio, MS PowerPoint, Mercury Quality Center, Sybase, MS-SharePoint, MS-Word, MS-Excel, Facets

Confidential

Business Analyst

• headquartered in Confidential
• is one of the nation's largest publicly traded health benefits companies, with approximately 9 million medical members. The project included the HIPAA Business Analysis and Quality Assurance testing activities and involves in HIPAA compliance, claims and Insurance and provides the different plans - to employer groups, government-sponsored plans, and individuals.

Responsibilities:

• Involved in claims submission and payment remittance retrievals by using ASCX12N 820 for the In- bound premium payments ASC x12N 834 for the Inbound Enrollment and Maintenance ASCX12 276/277 for the claims status enquiry and response and ASC X12 835 for the Health care Claim Payments
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers. The Claims were processed, co-pay is calculated, and the pricing is calculated using the IBM systems for both Retail and Direct Claims processing flow
• Was Responsible in finding the eligibility of the members and filing claims for the States Disability Insurance benefits for both short term disability who are not eligible for the Social security benefits and for the Long term disability customers who are qualified under Social security plan for the payment of benefits as a result or injury
• Performed Functional, regression, System Integration and User Acceptance Testing for the various applications.
• Managed multiple priorities, project plans, time frames and trade-offs while ensuring the clinical and administrative staff understood the final results of the projects, sharing detailed vision of cost-benefit analysis
• Executing System Test , Regression Test, User Acceptance Test UAT
• Created reports to satisfy user requests, data sampling, project analysis, or testing verification
• Tested user interface and navigation controls of the application using Quick Test Pro.
• Involved in writing and executing test cases using MQC based on the requirements
• Performed Back-End testing
• Used the Rational Unified process methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams using the Rational Rose
• Responsible for customer interface, requirements definition, general and detailed design, testing, maintenance and training programs and managed requirements using Rational Requisite Pro
• Developed associated project documentation, schedule, design specifications, test plan, test scenarios/scripts, performed gap analysis, and test tracking reporting/monitoring for all phases of testing including B2B user acceptance testing

Environment: Microsoft Visio, Windows XP, Java, JSP, IBM systems, Rational Requisite, Visual Basics, Rational Rose, Win Runner, SQL, Oracle, Load Runner, QTP, Sybase, .NET, Oracle.

Confidential

Business Analyst

I have worked on the project for Health Claims Scanning and Data Extraction OCR for HCFA 1500 and UB92 claims. I developed and managed needs analysis, requirements gathering, gap analysis, creation of vendor disaster recovery plan, design, layout, business rule development and associated software interface development and test documents, development, and EDI implementation insuring HIPAA compliance. The project had a budget of 800K and the system was anticipated to have an annual volume 1.5M claims.

Responsibilities

• Used SDLC basis of planning approach Microsoft Project used for Planning, Control, Resource Planning and Status reporting
• Involved in daily communications and face to face discussions with individual team members, the sponsor and key stakeholders. Presented project proposals and status to executive management
• Developed Business Cases as needed
• Writing Test Plans/Test Scenarios/Test Cases/Test Matrix.
• Developed Project Plans incorporating resources, schedule and scope using the Work Breakdown Structure
• Project Manager for the development of Medicaid reports for the state of NY
• Developed automation test scripts for performing regression testing on the application using Quick Test Pro
• Financial System Replacement and Warehouse Project Manager that identified the new process and software through requirements gathering and gap analysis, implemented Solomon and created a Financial Warehouse with data feeds from the core system for Claims, Service Accounting, and data required for regulatory reporting along with feeds from external sources. Budget 750K, Team of 25 matrix organization
• Change Management Process, Managed requirements analysis, process development and implementation of Serena Software Change Management Process
• Responsible for reporting Core System Upgrade for the Finance and Claims Module

Environment: Windows XP, SQL server, Rational Requisite Pro, MS Visio, TCL, SQL, Oracle, Visual Basics, HTML, Load Runner and Quality Center.

Confidential

Business Analyst

Confidential provides managed care services exclusively for government-sponsored health care programs, focusing on Medicaid and Medicare. CONFIDENTIAL Well Care offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. I was involved in enhancement for working on claims process, coordination of benefit pricing process.

Responsibilities:

• Helped to communicate business priorities to the organization to effect business solutions
• Created and maintained BRD to assist PM close basis while managing multiple projects
• Converted Business Requirements to the Functional Specification
• Involved in gathering clinical data and supported application development. Data includes patient's admission status, discharge details and transfers. Also tested claims and diagnosis reports of the patient
• Used Requisite Pro for the Requirement Documents Preparation
• Prepared Business Process Models that includes modeling of all the activities of business from the conceptual to procedural level
• Participated in process of preparing verification master plan to describe clearly and concisely the company's philosophy, expectations, and approach to be followed. Met with users to generate and review business test cases
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams thus defining the Data Process Model and Business Process Mode
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests. Implemented and monitored Individual Development Plans focusing on total performance, including both quality and productivity.
• Designed and implemented HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction. Populated ICD-9, EDI X-12 transaction sets 835, 837, 270, 271, 276, 277 and 5010, responsible for Claims processing, coordination of benefits and pricing process
• Monitored client expectations through client involvement and communication throughout the lifecycle of the project educate clients and stakeholders on the benefits and risks associated with the project.
• Worked with the Quality Management team to ensure that requirements documentation can be easily translated into test plans, and ensure that the proper testing plans have been completed.

Environment: Rational Unified Process, Rational Rose, Visio 2003, Office 2003,C, MS Project 2002, Ms FrontPage, Windows XP