Summary:

• Qualified professional with over 10 years of extensive experience in the field of Project Manager, Sr. Business Analysis and Data Analyst working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Adequate knowledge in Health Administration Claims processing auto adjudication , COB, EOB/Drafts, Claims pricing and testing, enrollment, Medicare, MMIS, Medicaid, CDHP consumer driven health plans .
• Expert in ERP architecture, Business process design, re-design, blue-printing, data analysis, business modeling logical and physical , ERP Security, functional design, technical design, application development, integration, and enablement.
• Managed the review, prioritization and resolution deployment related to day-to-day HRMS production support issues.
• Works with key users and the HRMS Technical Manager to prioritize and schedule issues resolution.
• Work with Agile/ scrum frame work, XP engineering practices, Kanban, Hybrid agile frame work. Use PMBOK processes as an overarching umbrella for project management.
• Initiated communication strategies to improve the flow of information and improve ownership between internal HRMS business units, upper management and across functional boundaries.
• Experience in B2B, B2C and Ecommerce portals web application developments.
• Experienced as a Business Analyst in using the iterative software development life cycle principles of Rational Unified Process to manage, develop and test distributed client/server, internet and intranet applications on heterogeneous environments.
• Experience in the Extraction, Transformation and Loading of data from multiple sources into Data Warehouse using Informatica Power Center.
• Expert in SSIS, SSAS AND SSRS.
• Provide expertise regarding the HRMS system including: workflow, interfaces, and troubleshooting.
• Project Management experience - Have successfully managed several key ERP Project Implementations for large scale Companies.
• Expertise in PeopleSoft in HRMS/HCM HR, Payroll North America, Payroll Interface ADP Connection , Benefits Administration, Time Labor, Talent Acquisition Manager TAM Candidate Gateway eRecruit , ELM, Performance Management, ESS and MSS.
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Excellent Knowledge in Electronic Medical Record EMR / Electronic Health Records EHR modules and process flow.
• Work closely with IT and PS development team to resolve daily production support issues within ERP system.
• Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.

Expertise in SQL Server Reporting Services SSRS .

• Deep knowledge of PPACA rules surrounding the Enrolment and Eligibility piece.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications.
• Familiar with HIPAA EDI transactions such as 835, 837 P, D, I 276, 277, 278 etc
• Worked as a Business Analyst and UAT Tester for ICD9 to ICD10 project on the Professional Claims side.
• Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.
• Good knowledge of Workflows and Content Management Tools.
• Experience in Change Management Process Identify, Analyze, Evaluate, Plan, Implement, Review and Close .
• Expertise in Procurement and Management Services
• Excellent skills in Project and Performance Management to support Strategic Planning, Goal Setting, Strengthen Accountability, Enhance Decision Making, and Improve Customer Service.

TECHNICAL SKILLS:

PROFESSIONAL EXPERIENCE:

Confidential

Project Manager

• Description: The HealthMarkets group of Insurance Companies is one of America's leading providers of affordable health insurance for the self-employed, individuals and families, as well as small businesses.
• Working as a Project Manager. I was involved in development of claim management data warehouse to assist claim professionals to analyze and administer the claims in an efficient manner. The operational data came from multiple sources and was then loaded into claim management data warehouse.

Responsibilities:

• Review and understand CMS regulations, data files and requirements that support Medicare D premium billing processes.
• Followed NCPDP rules to adjudicate and process the Medicare prescription drug claims.
• Participate in Systems testing and UAT followed by post production support created a workflow to distinguish between ICD-9 ICD-10 codes in cases of overlap.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System MMIS reports.
• Developed and conducted Business Process Analysis for an HCM upgrade from 8.9 to 9.0 for eight healthcare facilities.
• Respond to Request for Information RFIs for external clients and prospects to the FAS business.
• Lead multiple project teams of technical professionals through all phases of the SDLC using technologies including Oracle, Erwin, Data Stage, Data Warehousing, Websphere and Cognos.
• The project involved strategic change and operational improvements implemented around a PeopleSoft 9.1 HRMS application.
• Facilitate sprint planning, release planning, sprint retrospective, sprint review, and daily scrum meetings.
• Demonstrated proficiency in understanding the required certificates, licensures and documents required by NCPDP and Pharmacy Benefit Managers due to contract requirements and CMS regulations.
• Acted as Scrum Master Coach and Agile QA lead for over 20 scrum masters.
• Coach Product Owner, development team, and project stakeholders to adhere to scrum values and practices.
• Give leadership to organization to identify the ERP teams and other roles for the implementation plans.
• Participated in various Healthcare presales initiative for EHR applications, HIPAA 4010-HIPAA 5010 and ICD9 - ICD10 conversions.
• Develop implementation guidelines and principles for practice-based clinical applications, including various practice management and EMR systems.
• Develop and implement change control policies and procedures for EMR template change requests.
• Serve as firmwide support for all RFP and RFI requests. Manage RFP processes and procedures.
• Guided upper level management in Scrum and agile development principles.
• Managed an Internal Verification Validation Project around a PeopleSoft HRMS 8.9 application at the Office of DC Pensions.
• Built business requirements into the Medicare Advantage MA requirements database and created the Project Requirements Document for the three functional areas.
• Conducted sessions over MITA and practiced it. Worked over Companion guide.
• Interprets Claims Processing Business Rules, tests against MMIS functionality and translates differences into System Enhancements and/or Functional Defects.
• Conducted a crosswalk between the Billing Application and the HIPAA Implementation Guide.
• Document Trading Partner Migration Process Flow from HIPAA 4010A to 5010 create process flow diagrams and presentation materials and monitor production and release events.
• Coordinate with team members to ensure on time completion of proposals RFI, RFP, Proactive proposals and presentations .
• Worked on Health Insurance exchanges HIX and analyzed the data and worked with EDI NCPDP 5.1 considerations and implemented HIPAA regulations.
• Worked in mainframe environment and used SQL to query various reporting databases
• Worked with COBOL, JCL, and VSAM.
• Investigating and evaluating the SAP HCM Payroll system and the current functionality the client is utilizing, identifying the gap and risks.
• Facilitated JAD sessions for Requirement Validation and requirement gathering for the new MMIS.
• Conducted fit-gap sessions as the PeopleSoft Technical Lead for Adventist Healthcare, a large client implementing PeopleSoft HRMS Supply Chain 9.0.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Knowledge of Patient Protection and Affordable Care Act PPACA .
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.

Environment: Windows 2000/XP,NCPDP,RFP/RFI, Agile/Scrum ,Microsoft Office SharePoint 2007,MMIS, ICD-10 and ICD-9,Rational Requisite Pro, MS Office, SQL Server, Agile, PeopleSoft HRMS/HCM 8.8/9.1, MS Project, MS FrontPage 2003, MS Access, Erwin, Mainframe, SOA, COBOL, EDI, Documentum 2.0.,UML.

Confidential

Sr. Business Analyst/Project Coordinator

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Perform integration testing for a Medicaid Management Information System MMIS database conversion project.
• Identification and elimination of barriers to strict adherence to project timeline in order to align to Centers for Medicare and Medicare Services CMS regulation and timelines.
• Developed back end code using Core Java to implement technical enhancement by following Java Standards.
• Owned the entire reporting process. Interacted with the ETL team, developer s , management, and account holders to get the requirements, document them, design templates, and write specifications.
• Performs training for new Charter Business KMA personnel on our RFP process, policies, and procedures.
• Oversees the generation of weekly, monthly, and annual reports that reflect the status of all pending RFP submissions.
• Created numerous programs using SQR, Import Manager and Application Engine to load legacy data into PeopleSoft HRMS. Performed analysis on conversion issues, created new menus and applied customizations.
• Created and deployed competitive strategies to displace established ERP providers. Competitive displacements.
• Incorporated and implemented all the HIPAA standards, Electronic Data Interchange EDI , transaction syntax like ANSI X12, ICD-9, ICD-10 coding.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 codes.
• Develop online systems to support repeatable information to reduce reliance on subject matter experts Creation of RFP Database .
• Worked on Health Insurance exchanges HIX and analyzed the data and worked with EDI NCPDP 5.1 considerations and implemented HIPAA regulations.
• Introduced Scrum concepts and lean/agile development through formal classes at client sites.
• Key player in the global agile process initiative, teaching multiple courses on SDLC and concepts and providing input on best practices to multiple Scrum teams internationally.
• Improved ERP application long-term usage by establishing process for future enhancements.
• Performed analysis on a county customer's modifications to HRMS 7.51 in an effort to assist them in deciding how they need to handle business requirements differently in PeopleSoft HRMS 8.
• Member of the evaluation team in choosing the ERP solution in payroll.
• Work with multiple computer systems to determine member status as a Medicare member and eligibility for proper filing of Appeal and or Grievance issue.
• Performed GAP analysis for ICD-9, ICD-10 and EDI 5010 X12 Message Structure with the 4010 Structure.
• Developed multiple courses on requirements elicitation, requirements management, requirements analysis, and agile development with Scrum, delivering at multiple venues.
• Developing queries and creating reports daily using MS Access, and PeopleSoft HCM.
• Conducted an analysis to determine optimization for the second phase of an HCM implementation that was highly customized.
• Controlled and managed Oracle HRMS infrastructure, projects, budgets and schedules.
• Developed and implemented IT strategies and operational policies for the HRMS function.
• Managed and coached six-member HRMS IT team.
• Part of the project team to migrate existing vendors trading EDI documents via Value Added Network VAN onto our FTP server to reduce operating costs.
• Met with relevant stakeholders to obtain EDI contacts for all vendors to communicate testing schedules and ensured project completion.
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 utilizing the ICD-10 codes.
• Proposed strategies to implement HIPAA 4010 in the new MMIS system eventually move to HIPAA 5010.Facilitate HIPAA integration and applied ANSI ASC X12 standards for 837 P, I, D , 270/271, 276/277, 278, and 835 transactions.
• Managed the client's priority work list. Assisted the clients in resolving software issues with PeopleSoft HRMS and Financials modules.
• Interprets business needs, tests against MMIS functionality and translates differences into System Enhancements and/or Functional Defects.
• Substantial report development experience utilizing SQL Server Reporting Services SSRS , Cognos Impromptu, and Microsoft Excel.
• Propose strategies to implement HIPAA 4010 in the new MMIS system eventually move to HIPAA 5010.
• Assist as needed in the completion of all responses to all RFP RFI, and RFQ projects.
• Conducted end user for enterprise learning, HCM and Benefits.
• Led change management activities for client including communication plans and mapping out process flows for PeopleSoft HCM applications.
• Responsible for claim processing in MMIS.
• As a result of the Patient Protection and Affordable Care Act PPACA , Aetna must provide a rebate to enrollees on an annual basis.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Develop financial model to help predict effects of PPACA.

Environment:

Requisite Pro, Rational Rose, NCPDP,RFP/RFI, Agile/Scrum ,Agile, PeopleSoft HRMS/HCM 8.8/9.1, Mainframe, ICD-10 and ICD-9, Microsoft Office SharePoint 2010, MMIS,MITA,SOA, Erwin, COBOL, PL/SQL, HTML, Java, XML, MS Office, MS Visio, MS Access, DB2, EDI, UML.MMIS.

Sr. Medicaid Systems Development Security Business Analyst

Confidential

Responsibilities:

• Performs detailed gap analysis between client requirements and base system design, to identify areas for potential
• Modification or enhancement related to MMIS Medicaid Management Information System security.
• Experience working on NCPDP, EDI transactions and following norms of HIPAA.
• Managed team of up to 10 as a Scrum Master. Work included planning, monitoring, and delivering products on time and within budget.
• worked with data mapping team for ICD 9 to ICD10 for forward mapping of the diagnosis and procedure codes
• Analyzed the processes in medical coding and transition from ICD 9 to ICD 10.
• Created reports to evaluate provider performance relative to patient care and associated HEDIS measures.
• Oversees the workflow for proactive prospecting of opportunities by the RFP Specialist team.
• Analyzed issues with EDI transactions and fixed IDOCs to be submitted into SAP for order fulfillment.
• Lead the following Scrum-related meetings: scoping, sprint planning, daily standups, reviews, retrospectives, and demos.
• Writes, organizes and edits proposal content, ensuring that assigned proposals are in compliance with the RFP specifications.
• Integrated ERP system with external Loftware barcode scanning, standardized label printing
• Implemented Corvu Reporting upgrade coincident with the ERP system upgrade.
• Created lists of ICD9 - ICD10 CM/PCS codes, with reference to the usage percentile and provided to Stakeholders to determine if codes were best-fit or all possibilities.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records EMR and Electronic Health Records EHR software.
• Facilitated and resolved action items, issues, and risks for scrum teams and integration teams.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Effectively applied Scrum /Agile methodologies and enforcing project standards using Rally tool.
• Worked on PeopleSoft application upgrade from PeopleSoft HCM 8.8 to PeopleSoft HCM 9.1.
• Worked on CMS Center for Medicare and Medicaid Services checklist, MITA, HIPPA and GAP analysis
• Assists with the development of System Test Plan develops system test cases, scripts and system test data.
• Map the MECT checklist requirements with different MITA business process areas.
• Coordinates defect resolution with developers and retests resolved defects
• Created new security reports and maintained other security reports within MMIS system
• Reporting using SQL for different Query reporting.

Environment:

Rational Rose and Requisite Pro, NCPDP, MS Visio, Agile/Scrum ,PeopleSoft HCM 8.8/9.1,Microsoft Office SharePoint 2007, MS Project,HIPAA,MMIS, MS Access, ICD-10 and ICD-9, UML,MMIS, Mainframe, SOA,RFP/RFI, COBOL, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE JSP1.2 , XML, XSL, XSLT, HTML, Oracle 9i.

Confidential

Data/Business Analyst

Responsibilities:

• Gather requirements by conducting one-on-one meetings and brainstorming sessions with end users and SME and document the gathered requirements.
• Ensuring compliance with HIPAA transaction sets 837,270,271,276 and 277 to ensure standardization of EDI transactions.
• Manage software remediation of 16 applications to meet government ICD-10 billing code modification mandate.
• Reviewed state documents policies, manuals, business processes, systems documents, banners, bulletins from various divisions. Analyzed and performed quality assurance to determine areas impacted by HIPAA 5010 and ICD-10 related data.
• Mapped ICD codes and prepared final result summary documents with reports.
• Trained internal teams how to maintain the agile framework.
• To understand the Designed and developed entire Coventry integration framework with ERP and other legacy systems.
• Communicated status updates, ensuring scrum teams' awareness for any changes in the iteration.
• Managed full life cycle development with dispersed team following scrum framework.
• Provided training sessions for ERP team members, time clerks and managers on data entry sessions decreased data entry variances during parallel testing.
• Support Human Resources as the owner of ERP HRMS system.
• Performed GAP analysis to assess AS IS and TO BE scenarios between HIPAA 4010 and HIPAA 5010 and conversions of codes from ICD 9 to ICD 10.
• Design, configuration and implementation of SaaS contracts lifecycle management solution Selectica .
• Maintained the Change Management Register to track monitor changes which need to be incorporated in the subsequent releases.
• Involved in performing version control and defect tracking activities using Test Director and Rational Clear-Quest.

Environment:

Rational Rose and Requisite Pro, Agile/Scrum, Microsoft Office SharePoint 2007,MS Visio, MS Project,HIPAA,MMIS, MS Access, UML,MMIS, Mainframe, SOA, COBOL, ICD-10 and ICD-9, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE JSP1.2 , XML, XSL, XSLT, HTML, Oracle 9i.

Confidential

Data Analyst/Business Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Implemented Agile/Scrum as a project management methodology within DRL - Coached the software development team in using Agile/Scrum.
• Assist Medicaid staff in designing/modifying MMIS processing cycle reports.
• Perform a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Involved in the analysis of HIPAA compliance and EDI transaction sets and actively participated in the designing of the EDI transactions using the new HIPAA 5010 utilizing the ICD-10 codes.
• Proposed strategies to implement HIPAA 4010 in the new MMIS system eventually move to HIPAA 5010.Facilitate HIPAA integration and applied ANSI ASC X12 standards for 837 P, I, D , 270/271, 276/277, 278, and 835 transactions.
• Leading the enterprise initiatives like ESB Enterprise service bus , ECM Enterprise content management keeping MITA architecture in perspective.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Create technical design documentation for the data models, data flow control process, metadata management.
• All MITA business processes were reviewed and a feasibility study was conducted to integrate the EHR Provider Program business process into standard MITA business process.
• Extensively involved in the modeling and development of Reporting Data Warehousing System.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.

Environment:

Rational Rose and Requisite Pro, Microsoft Office SharePoint 2007,Agile/Scrum ,MS Visio, MS Project,HIPAA,MMIS, MS Access, UML,MMIS, Mainframe, SOA, COBOL, ICD-10 and ICD-9, PL/SQL, HTML, Java, XML, MS Office, MS Visio, DB2, Windows XP, NT/2000, HTML, Vignette Content management Tool, J2EE JSP1.2 , XML, XSL, XSLT, HTML, Oracle 9i.

Confidential

Business System analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process RUP to configure and develop process, standards, and procedures and create a Business requirement Document.
• Responsible for preparing Software Requirement Specification SRS and documenting them.
• Produced Initial Medicaid Information Technology Architecture MITA State Self-Assessment Report to support the current Medicaid Management Information System MMIS Replacement Project.
• Conducted JAD sessions during the client site visit to collaborating partners like Creehan Specialty Pharmacy IT Solutions - Pittsburg USA and Cystic Fibrosis Foundation CFS Washington- USA .
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange EDI .
• Documented various key elements of HIPAA compliance and made sure that they were understood by the development teams and ensured that the test cases written for the project were HIPAA complaint.
• Develops and execute testing strategies for MMIS system changes. Strong background in testing entire systems life cycle and skilled in testing various Medicaid software.
• Managed the team of consultants responsible for developing on-demand Medicaid Management System MMIS reports.
• Experience in an outsourced healthcare insurance operations environment and understanding of MECT and MITA.
• Extensively involved in HIPAA 5010 User Acceptance Testing UAT . Defined and maintained Test Cases for EDI transactions.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Analyzed and translated business requirements into system specifications.

Environment: J2EE JSP 1.1 , EJB 2.0 , Servlets 2.2, JMS, Java2 JDK 1.3 ,HIPAA, STRUTS,MMIS,JDBC2.0, XML, XSL, XSLT, Rational Rose, MS Access, PL/SQL, HTML, CSS, JavaScript, Websphere4.0,Oracle 8.0, WebSphere Studio Application Developer v5.0, Win2000, Unix AIX