- Business Analyst with 8 years of industry experience in identifying business needs, and determining solutions to business problems for complex software projects including system development component, business process improvement, strategic planning and policy development.
- Experience with full Software Development Life Cycle SDLC and project life cycle including Feasibility Analysis, Requirements Planning and Management, Application Design and Development, Testing, Implementation and Post-Implementation Validation, and Solution Assessment.
- Strong knowledge of Object Oriented Analysis and Design OOAD using Unified Modeling Language UML , Rational Unified Process RUP , Capability Maturity model CMM , Six Sigma DMAIC . Also worked using various methodologies such as Waterfall methodology, Agile Software Development, Rapid Application Development RAD , Joint Application Design JAD , and Prototyping.
- Experienced in Business writing skills and Technical writing skills in developing Business Case, Scope Document, Business Requirements Document BRD , Functional Requirements Document FRD , Non Functional Requirements Documents NFRD , Use Case Scenarios, Test Plans, Test Cases, AS-IS and TO-BE workflows.
- Proficient in Rational Suite including Rational Rose, RequisitePro, MS Visio, MS Project and MS Access.
- Also proficient with application support, claims processing, and customer service modules in Facets.
- Excellent communication skills and proficiency in interacting with the stakeholders, and Subject Matter Experts SME's to get a better understanding of the Business Process.
- Extensive experience with Business Process Management BPM system.
- Excellent knowledge of Health Insurance Portability Accountability Act HIPAA standards, Electronic Data Interchange EDI , and Implementation and knowledge of HIPAA code sets, ICD-9, ICD-10 coding, and HL7.
- Worked with ANSIX12 5010 and ANSIX12 4010 including the standards for medical EDI transactions like 837 medical claims , 835 medical claims payments , 270 eligibility inquiry , 271 eligibility response , 276 claim status , 277 claim status response , 820 enrollment , and 834 premium payments .
- Extensive knowledge of the gap between HIPAA 4010 and 5010
- Excellent knowledge of Medicare Part A,B,C, and D and Medicaid Health Insurance Policies, Personal Injury Protection PIP insurance, billing experience with life and disability in health plans with thorough understanding of CPTcoding, UCR, HCFA-1500 and CMS-1500 claim forms and reimbursement forms.
- Efficient in handling Change Requests by the client.
- Experience in White Box, Black Box, Unit, Functional, Integration, Back End and System Level Load and Stress Testing for many types of applications including web and client server applications.
- Good knowledge and understanding of Medical Management Information System MMIS
- Working knowledge and experience with SQL/PL SQL, HTML, and MS Access
- Excellent analytical and problem solving skills in designing, developing, and implementing innovative business processes using new approaches and technology.
Business Process Analysis Design, Requirement Gathering, Use Case Modeling, JAD Sessions, Gap Analysis, and Impact Analysis
SDLC, RUP, Agile, OOAD, and Waterfall
ISO, CMM, Six Sigma
C,C , SQL, PL/SQL, HTML, XML
Project Management Tools
MS Office suit, MS Visio, MS Project, MS SharePoint
Change Management Tools
UML, Rational Rose, MS Visio
Project Management Tools
Rational Rose, RequisitePro, Clear Quest, Clear Case, and MS Visio
HP Quality Center, Win Runner, Load Runner, and TOAD
Data Modeling Tools
Erwin, Informatica 7.1.1/6.5
Oracle 11i, DB2, MS SQL Server
Windows 95/2000/NT/XP/, 2007 and MS-DOS
Sr. Business Systems Analyst
Confidential is one of the largest nonprofit organizations in the nation that provides care through its various clinics and hospitals, provides insurance coverage through its various flexible plans and invests in continuous research and education to improve health of members, patients, and the community.
The scope of the project is to Implement a web based claims processing and management application to manage health insurance claims electronically. This software is a web-based electronic claims processing solution providing real-time patient insurance information. The application connects the organization to the largest all-payer network of commercial and government health plans nationwide to provide a wealth of real-time patient benefit information. Data is automatically translated to meet HIPAA compliance standards and the privacy of transactions is protected with the highest level of security.
- Analyzed the Business Modules and their impact on the current system.
- Responsible for starting RUP and UML Processes for creation of documentation to use by IT Team.
- Created Requirement Specification Documents based on interviews with End Users, JAD Sessions and analysis of their existant systems.
- Created Use Cases, Use Case Models, Work Flows, and System Specification Document Using RUP Methodology.
- Analyzed end-user requirements, their strategies, and their objectives to create Requirement Specification Documents, Use Cases.
- Used Component business modeling for improving strategic planning and efficiency.
- Assisted with the building EDI 837 I, D, P , 835, 277-U, 270/271, 276/277, 278, 820 and 834 transactions processing flow from the Trading Partners to the translator to the Mainframe and back to the Trading Partner.
- Work responsibilities primarily involved understanding the business logic, designing requirements, communicating them to the developers, generating documentation, designing use cases, creating various diagrams like State Diagrams, Sequence Diagrams as part of project.
- Maintained Traceability matrix throughout the project.
- Created standards / guidelines for business process modeling, Use Cases, Work Flows, Data Dictionary, and requirements specifications.
- Mentoring end-users on requirements specifications techniques and the software development life cycle.
- Scheduled meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Created transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837- I, P, D , 835 Remittances and others. Resource for UB92 and HCFA1500 billing format, transaction sets requirements, EDI development and Design, X12 protocols through Version 4010 A1 and newer, conversion needs and understanding of legacy EDI formats, such as UB92 Versions 4, 5, 6 and NSF.
- Analyzed requirements and formulated a Test Plan for functionality testing, navigation, and integration testing of the application.
- Involved in creating requirements that comply with HIPAA, HL7, and ANSI X12 format regulations to protect the privacy of the employee insured under any policy.
- Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange EDI .
Environment: MS Project, SQL, Rational Unified Process RUP , Rational Requisite Pro, Rational Rose, Clear Quest, Microsoft Visio, Windows 2000/XP, Mercury Test-Director, MS Visio, Business Objects
Confidential provides health care coverage to low-income Oregonians through programs administered by the Division of Medical Assistance Programs DMAP . Currently, more than 380,000 people each month receive health care coverage through the Oregon Health Plan. The project aims at building an Enterprise SOA Service-Oriented Architecture based system that will be developed on the Microsoft .NET Platform. The new Claims Processing MMIS Medicaid Management Information System will replace the old legacy system and will automate all the business areas with minimum human intervention. As a Business Analyst, I was involved with drafting the migration plan for the Claims Processing data which needed to be migrated from the Mainframe to the SQL Server environment. I was also involved with the HIPAA 5010 compliance for the new MMIS system.
- Gathered requirements from stakeholders for provider management and member management.
- Analyzed EDI X12 data elements captured by the existing system to validate it against the data elements required for new system.
- Proposed strategies to implement HIPAA 5010 in the new MMIS system.
- Analyzed different data cross-walks, complicated logic look ups required by different fields for the source to target transformations.
- Facilitated JAD sessions for Requirement Validation with Dept. of Health Human Services DHHS to gather requirements for the new MMIS.
- Identified and validatedbusiness rules and data elements.
- Developed the stakeholder list and created stakeholder assessment matrix to prioritize them.
- Developed and maintained a requirements work plan and assessed the performance metrics of the team members.
- Maintained a bi-weekly status report for the requirements team and incorporated the same to the PMOstatus reports send to CMS.
- Modeled the 'as-is' process flow and the 'to-be' process flow and analyzed the gap and developed the action steps to fill the gaps.
- Conducted risk analysis and developed mitigation plans.
- Conducted impact analysis when there is any change in the requirements and updated the Business Requirements Document BRD and Systems Requirements Specification SRS .
- Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
- Worked with legacy team in developing BRD for multiple system change requests and participated in system testing.
- Used Microsoft SharePoint as the version tracking tool for managing the requirements documentation.
- Developed the User Interface UI prototypes to capture and validate requirements and spike solutions to the current problem.
- Designed Functional Specifications for the target physical database.
- Developed UAT test cases associated with the functional requirements.
- Create monthly/weekly status reports to update the project schedules deliverable plan.
- Examined the system design deliverables validating it against the Request for Proposal RFP .
Environment: MS Office, Windows 2000, .NET, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Oracle, SOA, HTML
Confidential Application, which provides the quality level of Health services for customers. The web site and the supporting system are developed to provide Online insurance services to their customers and Agents. The insurance Application involves quotation tool and also enables the customer to complete the transaction after selecting the insurance plan, pricing, location details etc. Also agents are allowed to quote or complete the application online on behalf of the customer. This includes Health insurance, Policy and Claim Service modules.
- Involved in gathering and documenting the requirements that were critical to the business process and using those requirements to design application software using a Use Case approach.
- Interviewing several business area experts, asking detail questions and carefully recording the requirements in a format that can be reviewed and understood by both business people and technical team.
- Conducted Functional Requirement reviews and walkthroughs with the designers, developers and stakeholders.
- Created and maintained the Product Backlog.
- Participated in and at times conducted the daily scrum.
- Interviewed business users to gather business wants and needs around project ideas and translate them into business and technical requirements.
- Reviewed each iteration deliverables with the Product owner and Scrum Master.
- Understanding of HIPAA compliant ANSI X12 837 formats for both professional and institutional claims.
- 276/277 Claim Status Request / Response
- 277/275 - Claim Request for additional Information and Response
- 270/271 - Eligibility Benefit Inquiry and Response
- 835 - Claim Payment/Advice
- 834 Benefit Enrollment and Maintenance
- 837 Claims and Encounters
- Helped developers with the following list of HIPAA-EDI Transaction Code sets:
- Matched the requirements for programs such as Medicare and Medicaid which are part of the Social Security Act.
- Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
- Interacted with clients and end users in order to understand the process and gather User Requirements.
- Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
- Conducted UAT and User Trainings.
Environment Agile, MS Visio, MS Word, MS Excel, MS PowerPoint, MS Outlook, UML, html, SQL, MS Access.
The Tennessee Department of Health works to protect, promote and improve the health and well-being of Tennesseans and those who visit our great state. Keeping people healthy by preventing problems that contribute to disease and injury is the overall emphasis of the department. The project involves enhancement to an existing system, DOSS Derivative Operations Support System , that supports all of DAG's key functionalities including reconciliation, debt accounting, hedge accounting and non-hedge accounting,. The project also entailed integrating a FAS157 system primarily responsible for position reconciliation.
- Performed SWOT and Gap analysis for the new functionality requirements
- Worked with HIPPA rules and regulations to draft business rules and claim processes.
- Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
- Conducted JAD sessions.
- Conducted detailed GAP analysis and impact analysis. Analyzed current state and future state
- Responsible for processing claim in MMIS.
- Worked with different subsystems of MMIS in enhancement.
- Identified and documented the dependencies between the business processes.
- Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
- Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
- Responsible for checking NPI and approval of claim payment.
- Data modeling using UML.
- Extensively involved in mapping data from various sources to the target database tables.
- Helped improve the loading process for various external data into Oracle database.
- Work with business representatives to understand data marts requirements, data models, data flows, Facets on-line, priorities and ensure that IT works is appropriately aligned.
- Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
- Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model RUP Methodology .
- Responsible for teaching sessions for end user to tell how to use tools. Used MS Project for various planning and budgeting activities
Environment: Rational Requisite Pro 2001, UML, Rational Unified Process RUP , MS Office