PROFESSIONAL SUMMARY:

• Business Analyst with 8 years of experience in multiple domains, seeking to contribute critical thinking and planning skills to enhance quality, effectiveness and productivity.
• Excellent understanding of Business Requirements Gathering, Evaluating Database Sources, Translating Requirements into Specification/ Functional and Technical Documents.
• Experience in facilitating Joint Requirement Planning JRP sessions with Business User Groups, conducting Joint Application Development JAD sessions with IT Groups and Conflict Management with Project team members.
• Experience with Claims, Enrollment, Eligibility verification for Members and Providers, benefits setup, and backend payment cycle.
• Experience in developing Work Flows and Activities, Rule based Business Process Management using Pega Rules Process Commander PRPC , Decision tables, Decision maps, Declarative expressions, Constraints, and Indexes.
• Well versed with the usage of debugging tools including Pega Clipboard, RULE Inspector, Tracer and Log Analyzer.
• Experience with health care Systems: FACETS, NASCO. TPS, ITS Interplan Teleprocessing Services , QNXT, Medicare Part A, B, C, D and Medicaid systems.
• Experience in using Facets support systems to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834, 835, 837 270/271 transactions.
• Exceptional experience in SDLC Methodology for developing HIPAA EDI applications used by hospitals to completely automate payments posting for Medicare, Medicaid and commercial payers electronic payments files.
• In-depth knowledge of Rational Unified Process RUP methodology, Use Cases, Object Oriented Analysis and Design OOAD , Requirement Traceability Matrix RTM , Agile and XP methodologies.
• Competent in creating Unified Modeling Language UML diagrams such as Use Case Diagrams, Activity Diagrams, Sequence Diagrams, Component Diagrams
• Experience in UML, Visio, Rational Rose, Clear Case, Rational Requisite Pro, Test Manager, Rational Clear Quest Microsoft office Suite
• Extensive experience in developing Use Cases, creating Screen Mockups, conducting GAP Analysis and Impact Analysis, SWOT analysis, Cost Benefit Analysis, Risk Analysis
• Experience with Business Reporting Tools such as Crystal Reports, Excel
• Strong Experience in conducting User Acceptance Testing UAT and documentation of Test Cases. Expertise in designing and developing Test Plans and Test Scripts
• Solid business Data Analysis, Data Mining, Data Migration, Data Mapping, Meta Data and Reconciliation experience.
• Quick learner, strong organizational and planning skills, ability to work well under pressure, results-oriented, leadership, self-motivating and versatile in problem solving
• Excellent analytical problem solving skills and a team player with strong interpersonal and communication proficiency.

TECHNICAL SKILLS:

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Business Analyst

Responsibilities:

• Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements.
• Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, and Medical policy waves.
• Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD 10 such as EDI Claims Intake, FACETS- Claims Adjudication, Medical Management- Utilization Management, Case management and Provider Reimbursement- Provider Payment.
• Organized impacted systems into high, medium and low impact to help business analyze the level of effort for remediation activities and ease resource allocation work.
• Prepared use cases and data flow diagrams to analyze the impact of ICD 10 diagnosis codes embedded in different systems and applications
• Prepared and maintained requirements traceability matrix RTM throughout the project lifecycle.
• Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements.
• Validated that the system claim scrubber included editing based on the CEM published edits to ensure a positive 999 and 277CA transaction.
• Designed and developed Business Rules document about the Claim Component and HIPPA.
• Performed HIPPA 4010 to 5010 GAP analysis, requirement and testing for several EDI X12 transactions like 837I/P, 270/271 and 835.
• Specifications, Documentation and Construction of systems heavily relied on UML.
• Performed the Gap analyses of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
• Prepared Software Functional Specifications as per Business Requirements
• Designed robust 5010 testing and 4010 regression SIT and UAT Testing Scripts for the 5010 Project. Scripts were written on an application level and subset by payer resulting in over 600 combined scripts with a maximum of 70 testing scripts steps per script.
• Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis expected results for 5010 compliance.
• Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
• Took action in the process flow to prevent rejected claims from falling into limbo .
• Mitigated claim denial increase through a complete analysis of the application Claims Scrubber to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.
• Tracked all required resolutions required that were identified as needed from Vendors or Payers based on testing results.
• Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.

Environment: Facets, UML, MS Office Suite 2007, Cognos, Oracle, SQL, Rational Requisite Pro, ClearCase, Clear Quest.

Confidential

Business Analyst

Roles and Responsibilities:

• Prepare Project Requirements Document and Design Information Systems Business Solution
• Conduct Business Requirements meetings with clients to identify and document business Requirements
• Actively Involved in Pre-Analysis of project with SME Subject Matter Experts ,Developers
• Created Business Requirements and converted them into System Requirement Specifications
• Worked on HIPAA 5010 compliance and EDI 837transactions, ICD 9,ICD 10 Codes
• Studied and analyzed requirements to be achieved and brainstormed to gather effective requirements for a quality product.
• Worked on MMIS Claims payment and implementation, HIPPA compliance ANSI X12-837 EDI Transaction Code
• Generated various SQL queries whenever required and worked on the documentation of the databases
• Performed data analysis and Data mapping from source system to target system
• Created Functional Requirement Specification Document which includedUML, Use case diagrams, Scenarios, activity, work Flow diagrams and data mapping, and Data modeling with MS VISIO.
• Demonstrated experience implementing MDM foundational programs such as master data security, master data quality, master data workflow, etc.
• Performed Impact and Cost Benefit Analysis For Project
• Creation and Maintain of Workflow Plans and Artifacts
• Extensive experience in ETL process consisting of data transformation, sourcing, mapping, conversion and loading.
• Worked on the Documentation of databases like the SQL, Oracle and did the documentation for the Data Marts.
• Wrote complex SQL queries like Joins, Update, Stored Procedures, Indexes, Reports, ETL packages to understand the low level requirements
• Through understanding of Rational Unifies Process RUP , Unified Modeling Language UML , and Rational Suite including Rational Rose, Requisite Pro, Rational Clear Case, Rational Clear Quest and Object Oriented Analysis.
• Implemented Business Intelligence BI to help users make better business decisions.
• Conducted workflow, process diagram and GAP GAP analyses to derive requirements for existing systems enhancements.
• Assisted with user testing of systems, developed and maintained quality procedures and ensured that appropriate documentation was in place.
• Proficient in creating Use Cases, Sequence Diagrams, Collaboration Diagrams, Activity Diagrams, Class Diagrams, Business Intelligence Tools etc.
• Excellent Business writing skills in writing Business Requirement Documents Specifications, Functional Specification Documents etc.
• Worked on the Data warehouse for the requirement gathering and updated to the SharePoint
• Created business rules, business vision document, business glossary and implementation up to functional and technical specifications.
• Extensive experience in managing project requirements, which includes requirement gathering, requirement rating/analysis and requirement priority assignment. .
• Participated in Design walk-through with end users to baseline the business architecture.
• Performed GAP analysis on the existing solution and its transition into the new HIPAA 4010/ 5010.
• Worked on the Reporting and ETL tools to do reverse engineering writing SQL Queries
• Assist the business areas and technical teams to develop or update the test scenarios to ensure sufficient testing of ICD-10 impacted key system functions technical changes, as well as enterprise wide integration testing.
• Created data flow and sequence diagrams to describe how EDI Healthcare Transaction set 837 was used to submit health care billing information.
• Implemented Automation Testing using Quick Test Professional, Mercury Quality Center
• Involved in preparing a simple and detailed User manual for the application, for an intended user.
• Experience in Data Modeling and documentation of the database architecture
• Developing and executing test cases Change Control Requests CCRs and updating scope with new changes.
• As a Business Analyst/Data Analyst involved in business requirements, analysis, design, project planning
• scheduling, creating UAT Test Plans / Test Cases
• Developed Test Cases from Use Cases, reviewed Test Plans to ensure Use Cases accurately
• Reflected Functional and User Interface testing.
• Wrote SQL Queries and did the Documentation for the Databases
• Designed the Test Plan and Test Cases for all processes and Web Services

Environment: RUP, UAT, GAD Gap Analysis Document , Microsoft Office 2003 Professional Outlook, Word, Excel, Visio, Access , Test director, Abinitio, HTML, SQL, Quick Test Professional, Mercury Quality Center, BAM, ESB.

Confidential

Business/System Analyst

Responsibilities:

• Responsible for Requirement gathering, Business Process flow, Business Process Modeling and Business Analysis with Document and Records Management.
• Worked with the business community to define business requirements for RISIS Refugee and Immigrants Support Information System Application for Refugee Case management and analyze the functional requirements and gathered the requirement from stakeholder and SME's.
• Conduct Joint Application Development JAD sessions and interviewed Subject Matter Experts SMEs , asking detailed functionality aspects of business process and carefully updated the information to the requirements in an easily understandable format.
• Facilitated JAD sessions with management, users and other stakeholders to define the project and to reduce the time frame required to complete deliverables.
• Prepared and presented Business Requirement Document BRD , Functional Requirement Document FRD and involved in sign-off process including Use Cases and UML diagrams to derive consisting understanding.
• Worked closely with the UI team to model the screens, which met User defined requirements and also company standards.
• Performed Gap analysis by identifying existing technologies, documenting the enhancements to meet the end state requirements.
• Review prototypes, solution blueprints, and project scope to ensure that the needs of the business are being met.
• Used the Rational Unified Process Methodology on the project.
• Constant liaison between Business Unit and IT, translating the requirements to the IT and web production teams in building their HTML for the projects and clearing doubts between stakeholders.
• Analyzed business requirements and segregated them into Use Cases. Created Use case diagrams using MS Visio according to UML methodology.
• Created Screen mock up to illustrate new requirements and alignment around project scope using MS Visio.
• Responsible for managing the documented System Requirements and Requirements Traceability Matrix using MS Excel.
• Responsibilities included Test Planning, Test Case development and test script execution for Integration, Regression, Performance, Functional and System Testing.
• Involved in creating detailed test plans and testing strategies and ensure these are executed extensively, which includes executing SQL queries to retrieve data and test.
• Provided support for User Acceptance Testing with UAT cases and resolving any issues with the users and performed UAT and participated in writing test plans, and developed different testing strategies like Black Box testing.
• Manage day-to-day project activities and coordinate tasks with vendors and internal teams. Create and Review RFP and RFI forms for software vendors.

Environment: HTML5, MS Office Suite, MS Visio, Quality Center, Oracle, SQL, PLSQL and Windows 7.

Confidential

Sr. Business Analyst

Responsibilities:

• Coordinating work arrangements for Coventry Health Care affecting vendors, provider networks, enrollment and eligibility, claims/payments, pharmacy, clinical, member help desk, prior authorizations, filing and EDI/data exchange requirements for the State of Florida and with Coventry Health Care, training, and joint policy/procedure alignment affecting Florida.
• Organized joint project team, milestone exit criteria, and communication plan with stakeholders. Prepared weekly status reports and escalation strategy for high impact customer issues/risks.
• Coordinated SME support for county-level provider network approvals with Coventry Health Care.
• Reconciled vendor support arrangements with Coventry Health Care and special contracting needs.
• Coordinated management responsibility and information requirements for member enrollment, claims, and encounters.
• Developed a detailed ICD-10 remediation project plan for transition of applicable clinical areas for member hospitals, regional hospitals, affiliated hospitals, clinics, and hospital departments. Work collaboratively with the client to develop the project charter, project milestones and reporting documents to be used throughout the project to track progress
• Monitored the program/project from initiation through delivery and evaluates their clinical and business processes to become ICD-10 compliant. This includes leading requirements definition, gap analysis and creating crosswalk plans to meet targeted milestones. Coordinate with data governance, charge analysts, physicians and clinicians.
• Coordinated data management, EDW, and business rules with Coventry Health Care affecting 270/271, 276/277 EDI file types and interface requirements to Florida Medicaid system.
• Vetted process and procedures to support clinical/pharma prior authorizations utilizing Coventry Health Care tools and procedures until such time responsibility reverted to CareSource.
• Based on activity in Florida, reused key tasks, durations, resource map to build standard MS Project 2010 implementation template for similar expansion efforts with Coventry Health Care into new state level markets.
• Reconciled member/provider portal responsibilities and member help desk procedures

Confidential

Business Analyst

Responsibilities:

• Gathered business requirements from the Business team and generating system workflows.
• Design Impact Analysis Documents IADs for GL- AP, GL-AR Summary - Reconciliation and other high level Business Reports Requests.
• Worked on PEGA and PBM.
• Worked on TMF in PEGA 5.5. Automated unit test cases.
• Involved in creating the targeted questionnaire for SMEs and Business users for elaborating requirements.
• Extensively worked on Pega Clipboard debugging tool.
• Initiated with a comparison report of migration of 4010 to 5010. 270 Eligibility, Coverage or Benefit Inquiry V4010X092A1 vs. 270 Eligibility, Coverage or Benefit Inquiry V5010X279 , 278 Prior Authorizations
• Validated the EDI 837-claim billing professional, institutional and dental claims 835 remittance advice or payment claims adjudications.
• Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with
• Participated in JAD sessions / conducted interviews for analyzing business requirements and reviewing them with business and technical teams.
• Designed and developed Use Cases and UML models using Microsoft Visio.
• Developed current and future state workflows of Ambulatory practices in MS Visio.
• Prepared the cost estimate for the business analysis involvement of the project.
• Prepared the BRD and conducted reviews with the stake holders.
• Writing change requests follow up with the respective teams on the impact and action.
• Reviewing the test cases and requirement traceability matrix along with the testing team.
• Tracked the project status in MPP, prepared the project status reports and represented the BA team in the PMO meetings.
• Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrollment and benefits, batch jobs corresponding to the claims 837 and real time transactions like 270/271/276/277.
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using General equivalence Mappings GEM .
• Involved in Customer UAT along with the Development testing teams.
• Participated regularly in walkthroughs and review meetings with PM, QA Lead and development teams.
• Assisted the PM in setting up realistic expectations and in evaluating the impact of change requests and risks and conducted project related presentations.

Environment: MS Visio, MS Project, MS Office Suite, Word, Excel, Access, Power Point, Outlook . Sybase, SQL Server, Pega System, FACETS 4.41 4.51, Agile, DB2, .NET, SAS, Lotus Quickr, IBM Process Modeler, Windows XP, UML, Mercury Quality Center.