Career Summary:

• System Analyst with over 7 years of experience in Healthcare and Pharmacy domain.
• Extensive working experience with TriZetto's Facets tool.
• Profound understanding of insurance policies like HMO and PPO and proven experience with HIPPA 4010/5010 EDI transaction codes such as 270/271 inquire/response health care benefits , 276/277 Claim status , 834 Benefit enrollment , 837 Health care claim .
• Experience with Trizetto Facets 4.71, 4.81 and 5.01.
• Excellent working knowledge of SQL Server Reporting Services SSRS , SQL Server Integration Services SSIS , SQL Server Analysis Services SSAS .
• Ensured accurate Transmission of the eligibility file and membership file to vendors and delegates as a result of the annual benefit changes.
• Experience in Forward mapping and backward Mapping analysis of ICD 9 ICD 10 conversion for CM Diagnosis Codes and PCS Procedure Codes .
• Expertise in EDI HIPAA 4010-5010 project to convert EDI x12 healthcare 4010 transactions into 5010 complaint transactions.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider and Billing Modules of Facets.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Provided analytical solution to the customers for Facets Production Issues.
• Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Strong knowledge of Use Cases, Sequence Diagrams, Collaboration Diagrams, Activity Diagrams, and Class Diagrams.
• Experienced in creating Use cases, Cross-functional flowcharts, activity diagrams and sequence diagrams.
• Extensive experience in Functional, Integration, Regression, User Acceptance UAT , System, Load and Black Box Testing.
• Provided major corporate clients with reports documenting the re-engineering process for identified administrative tasks and functions which included defined goals, objectives, critical success factors, cost analysis, administrative analysis and recommendations.
• BA/PM to evaluate business pain points, designed and implemented Business Process Reengineering methodology, and to improve business revenue through improved employee performance. cost, service, quality and speed
• Good Management, Execution and Documentation skills
• Expert in application/system development life-cycles concurrent development strategies, process streamlining, iteration modeling, rapid application development RAD/RUP/UML , and legacy/waterfall methodologies.
• Excellent knowledge of MS Office especially MS Excel, Power Point, Word etc

Business Skills:

• Business Plan development and requirement gathering and documentation
• Business case development including use cases and test scripts.
• Gap analysis reporting of 'as-is' and 'to-be' business environments.
• Iterative approach to project deliverables, including JAD sessions and peer review.
• Project management support through performance metrics and risks management logs.

Technical Expertise:

• Modeling Methodologies Agile, Rational Unified Process RUP and Waterfall
• Process/ Modeling Tools Rational Rose, MS Visio, Lombardi
• Databases MS Access, SQL Server, SSIS SSAS SSRS
• Quality Management HIPAA, CMMI, CMM
• Languages SQL HTML, C, C
• Operating System WINDOWS 98/2000/NT/XP
• Office Tools MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, SharePoint
• Project Management MS Project
• Healthcare Tools Trizetto Facets 4.51, Claredi, Amisys, QNXT

Professional Experience:

Confidential

Business Analyst

Responsibilities:

• Studied business requirements and conduced User Interviews to identify and document the data discrepancies and their sources as related to Government Contract Compliance GCC , Government Disclosures, Government Pricing, Customers, Products, Product pricing.
• Prepared Test Plans for each release, written Test Cases and executed them as part of Functional Testing. Prepared Test Reports and Deliverables and submitted for version releases.
• Worked on Re-engineering, Designing, Developing Implementing Medicaid Management Information Systems MMIS for State's Medicaid Program
• Create the accumulation Rules in Processing System. The Blue Exchange Provider Tool - Enhanced Eligibility Iteration 4 EEI4 mandate requires BCBSM to respond to the provider request for eligibility information HIPAA 270/271 with accumulation amount.
• Incorporated Rational Unified Process RUP to create Requirement Document Specifications using Visible Analyst.
• Worked on Re-engineering, Developing Implementing Prior Authorization Web Systems/Applications interfaced with MMIS
• Set claim processing data for different Facets Module.
• Tested HIPAA regulations in Facets HIPAA privacy module.
• Tested and delivered Inbound/Outbound Facets interfaces.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Enhanced test cases using GUI checkpoints, Database Checkpoints, Text checkpoints and Bitmap checkpoints
• Data Warehouse application development, support and maintain activities using Microsoft SQL server, SSIS, PL/SQL, Oracle database technologies
• Understanding of the practices and methods of Business Process Re-engineering.
• Experience in testing HIPAA EDI Transactions.
• Worked with in the areas of Clinical, Corporate and Finance, Pharmacy, Sales, Provider Network and identified the use of ICD 9 codes and prepared documents for the conversion of ICD 9-10 and vice versa.
• Conducted JAD project team and came up with the best solution to setup Accumulation Rules in the system.
• Used gap analysis framework to identify AS-IS processes of claims transactions of HIPAA X12 4010/4010A standard and TO-BE processes ICD-10-CM and ICD-10-PCS compliance requirements of 5010 standard
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Performed impact analysis for deadliness of ICD-10 conversion.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process Pre-Adjudication .
• Worked intensively on FACETS 4.6.1 for audit trails made on the used account and check and store information related to the HIPPA authorizations
• Wrote use cases, prepared use case diagrams using Rational Rose UML and followed Agile at every stage of the processes
• Developed the business crosswalks for 837 P, I, D , 835, 834, 270, 271 and 276/277 according to HIPAA implementation rules
• Conducted user interviews, gathering requirements, analyzing the requirements using Requisite pro
• Responsible for customer interface, requirements definition, general and detailed design, testing, maintenance and training programs and managed requirements using Rational Requisite Pro
• Conducted analysis of HIPAA compliance and took part in discussions for designing the healthcare transactions to be HIPAA 5010 compliant
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships
• Identify Member, Provider, Coverage, Medicare, and Medicaid
• Provider inquiry about the status of claims. This involved checking the MMIS claims subsystem to see the status of claims sent and informing the providers if the claims have been suspended / denied or paid.
• Played key role in defining test automation procedure and standards, creating Win Runner and QuickTestProfessional scripts for all the modules, which reduced the regression cycle drastically and improved the testing efforts for daily builds.
• Using Dynamic SQL statements constructed and executed dynamically during run time, based on supplied users.
• Established a RUP Rational Unified Process centric business analysis methodology.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Deployed Map Viewer and Integrated Map builder with OBIEE by creating the Spatial Data in database and Created different Maps using Different Themes, Colors and Markers.
• Planned and defined system requirements to Wire Frames with Use Case, Use Case Scenario and Use Case Narrative using the UML Unified Modeling Language methodologies.
• Evaluated testing results for each potential release build using Test Director, Quality Center and Bugzilla reports, listing summarized bug information in priority sequence, recommended viability of release for production.

Environment: Windows, OBIEE 10.1.3.4.1, Windows, Window NT, Linux, Mainframe, Solaris IBM Web sphere, Apache Tomcat, IIS 6.0, Web Logic, Java, SharePoint, MS Office, Quick Test Pro 8.2, Mercury Quality Center 9.0, Load Runner 8.2, Sun Java, MSJVM, Oracle 8i/9i/10g, SQL Server, DB2, Toad, MS-Project.

Confidential

Business Analyst - -Business Process Reengineering

As Business Analyst Responsibilities:

• Gathering business requirements, documenting them, writing scope documents and use cases.
• Involved in meetings with Business process owners, SME subject matter experts and IT professionals for requirements gathering and definition.
• Developing business strategy and life cycle approach for the BPR.
• Designed dynamic SSIS Packages to transfer data crossing different platforms, validate data during transferring, and archived data files for different DBMS.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases
• Instrumental role in introducing and enforcing new Scrum methodology in MHS with the Express One methodology, a new approach to requirements gathering, software development life cycle SDLC process and software testing life cycle STLC .
• Highly proficient in Business Process Redesign BPR , developing Business Process Flows, preparing graphical depictions of Use Cases including Use Case diagrams, Activity diagrams, Sequence diagrams, Class diagrams and Collaboration diagrams based on UML methodology.
• Developed DTSX packages to extract, transform and load into the Campaign database from OLTP database using of SQL Server Integration Services SSIS .
• Expert in ICD 9 10 Conversion Analysis. Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers. Worked on ICD 9 codes and gathered future requirements based on ICD 10 codes. Managed creation of sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Worked closely with the project manager, business lead and technical lead to identify, research and escalate issues and risks to the appropriate work stream for resolution
• Organized weekly and biweekly meetings with testers to discuss testing progress and address any major concerns with the testing effort
• Designed SSIS Packages to extract, transfer, load ETL existing data into SQL Server from different environments for the SSAS cubes.
• Developed use cases, and traceability matrices to better assist software development.
• Intensive working on the current ICD code conversion from ICD 9 to ICD 10, assisting and leading various teams by complying with already going works in the health care domain and work with the conversion.
• Sent weekly dashboard reports to management with updates of testing progress
• Involved in planning and implementing both high-level and detailed system and integration test plans
• Led and managed the User Acceptance Testing UAT for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Attended weekly testing status calls to update corporate on our testing progress and address any testing concerns
• Responsible for understanding the As Is business process and defining the To Be business process.
• Worked with the project manager to ensure project sign off closing procedures are adhered to
• Utilized RUP Rational Unified Process to create use cases, activity, class diagrams and workflow process diagrams.
• Performed overall Requirements Management and built the Requirements Traceability Matrix.

As Quality Assurance Analyst Responsibilities:

• While working on requirements of the 835 HIPAA project, jumped half way in the 820 report project, continued working on 835, 276 / 277 and HIPAA EDI Transactions across enterprise, meanwhile new project initiation of 4010 to 5010 migration began
• Used TriZetto HIPAA Gateway to comply with HIPAA standards 270/271, 276/277 837 for EDI transactions
• Tested the ANSI X12 Version 4010 / EDI transactions HIPAA like 270, 271, 837P, 837I, 835 remittances
• 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
• Did the forward and reverse data mapping between the fields in mainframe and QNXT.

Environment: MS SQL Server 2005, Rational Reqpro, Rational Manual Tester, Rational Test Manager, MS Share Point

Confidential

Business System Analyst

Responsibilities:

• Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates generated and maintained clinical data security policies and procedures.
• Created SOW for documenting established procedures.
• Documenting the impact of codes and the corresponding crosswalks associated with the claims and benefits on payer side.
• Worked on Data Mapping to map Facets data to outbound eligibility extracts
• Involved in claims submission and payment remittance retrievals by using ASC x12N 834 for the Inbound Enrollment and Maintenance ASCX12 276/277 for the claims status enquiry and response and ASC X12 835 Explanation of Benefits for the healthcare claim payments.
• Built, implemented and supported system solutions for Facets applications
• Identify and address areas of discontinuity between ICD 9 and ICD10 so as to avoid unnecessary mappings.
• Created documents on medical case management.
• Help in preparing the training material and other documentation materials of the providers and insurance companies using the software supporting ICD 10.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process Pre-Adjudication
• Involved in claim adjudication process of facets application
• Worked on the EDI 834-file load to Facets through MMS Membership maintenance sub-system
• Worked with FACETS edits and EDI HIPAA Claims 837/835/834 processing.
• Worked with FACETS, E-Billing and EDI HIPAA Claims 837/835/834 processing including Medicaid.
• Tested the HIPPA EDI, 834, 270/271, 276/277, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.
• Provide input to estimates for project management and change management activities through analysis of requirements effort, resources, and technology.
• Developed Use Case diagrams and process flow diagrams using Rational Rose and MS Visio.
• Actively prioritized and managed requirements throughout SDLC with all key stakeholders
• Supported QA in the definition and execution of integration and system 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
• Created reports to satisfy user requests, data sampling, project analysis, or testing verification
• Used the Rational Unified process methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams using the Rational Rose.
• Created Meeting of Minutes documents that would cover all the important issues and decisions taken internally as well as with the client.
• Worked on cross-functional team to deliver software systems as per the customer expectations.
• Updated the requirements and prepared comprehensive Business Requirements Document BRD that provided the appropriate scope for the users and management to make appropriate decisions.
• Created Data Flow Diagrams DFDs and ER diagrams for domain modeling.
• Played a key role in planning UAT and implementation of system enhancements and data migration and conversions.

Environment: Microsoft Visio, Windows XP, Rational Requisite, Rational Rose, Load Runner, .NET, Oracle

Confidential

Business System Analyst

Responsibilities:

• Performed Requirements Gathering and Analysis, interviewed the SME Subject Matter Experts , and ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
• Facilitated Joint Application Development JAD Sessions for communicating and managing expectations.
• Use HIPAA transactions to interface with Third-Party Administrators TPA also various proprietary file interfaces for TPAs not supporting HIPAA transactions.
• Develop health and welfare fund and/or TPA to administer all member benefits and payment.
• Design Plans to pay provider based on specific reimbursement arrangement.
• Manage the Requirements Business as well as System requirements , performed requirements analysis along with the creation of Use Case Scenarios. Modeling of the business and application using Rational Unified Processing RUP and Unified Modeling Language UML .
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation Verification process.
• Created Process Work Flows, Functional Specifications, and responsible for preparing Functional Specification Document FSD .
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the proposed system.
• Support Internal and external auditors for department audit.
• Performed Defect Tracking and Change Control Procedures using Quality Center and Configuration Management and Version Control using Rational Clear Case.
• Participated in developing test plans and test procedure templates and guidelines to be used by the project team with detailed screen layouts with regards to various types of corporate actions.
• Was involved in Functional System Testing, Integration Testing, Regression Testing, and User Acceptance Test using the test cases given by the client before releasing the application.
• Involved in the development of Test Plans, Test Cases and Expected Results, and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Provided assistance in other concurrent projects, especially in Regression Testing, in order for the team to gain time, before the clients could proceed to the system's User Acceptance Testing UAT
• Effectively logged and managed defects found during project system testing, and successfully interacted with the offshore development team to provide input for system fixes.

Environment: M.S Word, Excel, PowerPoint, SQL, MS Visio, Rational Tools, MS Access