SUMMARY:

Over 7 years of professional experience as Business Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.

• Extensive experience in the development, implementation and integration strategies towards a team oriented environment, utilizing quantitative and qualitative analytical skills. With ease in communicating/converting clients vague/non-technical requirements into precise/concise representation to the team.
• Experience in developing detailed functional specs through JADsessions, interviews, on site meetings with business users & development team.
• Documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document) and Non-functional Requirement Document.
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile& Waterfall life cycle
• Experience in interviewing Business users & SME providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• Test Case writing (manual/automated test cases) and Conducting Tests (Integration testing, Regression testing)Black Box/White Box testingUAT (User Acceptance Testing).
• Analysis & Design (Use Case, Sequence and Activity diagrams).
• Writing Manuals (System guides, training material for business users and Deployment guides).
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users
• Good knowledge and extensively used RDBM, SQL, along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with data analysisdata mapping and dimensional modeling experience in decision support systems (data marts) using Star Schema.
• Work experience in data warehousing projects dealing with ETL (extraction, transformation, load) using Oracle
• Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Experience with HIPAA compliance (4010 & 5010) and Healthcare systems
• Experience with Medicare, Medicaid, Medigap & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997,NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Experience with health care Systems: FACETS, Medicare Part A, B, C, D, Medicaid systems.

TECHNICAL SKILLS:

Methodologies: SDLC, RUP, UM, Agile.
Project Management: Microsoft Project, Microsoft Office.
Modeling Tools: Rational Rose, Microsoft Visio.
Change Management Tools: Rational Requisite Pro, Clear Quest, Test Director.
Version Control Systems: Rational Clear Case.
Testing Tools: Rational Enterprise Suite, Test Director, Win Runner.
Languages: C, C++, Java, .Net, XML, UML,HTML. Databases: Oracle, MS SQL Server, MS-Access Operating Systems: Windows Family, Familiar with UNIX and LINU RDBMS and Databases: SQL Server, Sybase MS Access Reporting Tools: Business Objects

EDUCATION:

Bachelors in Business studies

Client: Confidential, May12-Current Position: Sr Business Analysts, Phoenix AZ Environment: Cosmos, Diamond, Facets, Unison, Agile, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS Excel, Clear Case, Clear Quest, SQL
Project Description: UHG is an operating division of UnitedHealth Group, the largest single health carrier in the United States. Our family of companies delivers innovative products and services to approximately 70 million Americans. United Healthcare's nationwide network includes 704,966 physicians and health care professionals, 80,000 dentists and 5,580 hospitals. Our pharmaceutical management programs provide more affordable access to drugs for 13 million people .As a part of Portal team, we strive to provide the best online secure services to members and providers for accessing various information.
Project 1: Worked on secure portal /Non secure Portal/FAD.
Project 2: Worked with Member team on PRD's Creation.

Responsibilities:

• Analyze and document business requirements for secure Physician web portal and secure Member / Customer web portal.
• Write Project Requirement Documents (PRDs) which are standardized documents describing business needs, summary descriptions, dependencies, etc. Distribute for review and approval according to Requirements and Solution Analysis (RSA) process.
• Translate business requirements into technical requirements for IT development teams.
• Participate in high-level technical solutioning sessions
• Report project status, risks, roadblocks, etc, to immediate manager.
• Conduct User Acceptance Testing (UAT) on behalf of project stakeholder and review testing results for approval.
• Perform Operations & Maintenance tasks (O&M) including reviewing help desk requests, determining nature of problem / root cause analysis, assign to appropriate systems area for resolution, and monitor progress and communicate status to stake holder.
• Involved in Prod Verification and Production support.
• Worked on Member team for requirements Gathering, analysis and Documentation.
• Gather and organize information on problems or procedures.
• Analyze data gathered and potential solutions
• Confer with personnel concerned to ensure successful functioning of newly implemented systems or procedures.
• Develop and implement records management program for filing, protection, and retrieval of records, and assure compliance with program.
• Review and confer with management and users about format, distribution, and purpose, and to identify problems and improvements.
• Document findings and prepare recommendations for implementation of new systems, procedures, or organizational changes.
• Design, evaluate, recommend, and approve changes

Client: Confidential, Syracuse, NY Aug 11-May 12 Position: Business Analyst Environment: M2, Agile, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS Excel, Clear Case, Clear Quest, SQL
Project Description: WellPoint, Inc. is the largest health benefits company in terms of commercial membership in the United States. Through its networks nationwide, the company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts.
Project: (Up-gradation of HIPAA 4010 to 5010 and ICD 9 to ICD 10) Up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously.

Responsibilities

• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and impact, benefits and risks of ICD-10 code application.
• Re-Organize the collected data and prepared documentation for implementation.
• Constant touch with all the submitters of part A and B helping them with transition from 837 4010 to 837 5010 transaction.
• Vendor Management –Work as a facilitator for Testing Efforts and New Requirements between theHealthcareCompany and its various Vendors.
• Helped in gathering requirements for making TPA for third party vendor.
• Check test files and production files in M2 and update PIMS with any additional or changed information of providers.
• Coordinated the upgrade of Transaction Sets 837P, 837I and 835 to HIPAA compliance.
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Did gap analysis for HIPAA 4010 837P, 837I and 835 transactions and HIPAA 5010 837P, 837I and 835 transactions.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD. Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Attended daily SCRUM and guided QA and Developer regarding the defects, Technical Specification Documents.

Client: Confidential, Columbus, OH Apr 10-July 11 Position: Business Analyst Environment: Facets 4.48, Agile, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel Clear Case, Clear Quest, Quality Center, SQL, Oracle 9i, DB2, JAVA
Project Description: UnitedHealth Group is a leading health care company, serving more than 75 million people worldwide. Our family of companies touches nearly every aspect of health care, helping people live healthier lives. As a leader in the health benefits and services industry, our six businesses — United Healthcare Employer & Individual, United Healthcare Medicare & Retirement, United Healthcare Community & State, Optum Health, Ingenix, and Prescription Solutions — offer exceptional service, broad capabilities and enduring value in creating a modern health care system.
Project 1: (Up-gradation of HIPAA 4010 to 5010 and ICD 9 to ICD 10) Up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously
Project 2: (Facets Up- gradation)
The objective of the project was to upgrade Trizetto's Facets application software from version 4.48 to 4.60.I worked in Health care claim module and Enrollment module.

Responsibilities:

• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance
•  Did gap analysis between  ICD 9 and ICD 10
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts
• Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management system
• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance.
• Involved in claim adjudication process of facets application
• Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions
• Utilized Agile Methodology to configure and develop process, standards and procedures
• Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEM
• Did gap analysis and impact analysis for the facets up gradation system 4.48 to 4.60
• Worked on customization screens/reports related Enrollments, and Providers in Facets.
• Worked on developing the business requirements and use cases for Facets batch processes; automating the billing entity and commission process
• Attended daily SCRUM and guided QA and Developer regarding the defectsTechnical Specification Documents and Mapping Documents
• Documented UAT plan for the project to ensure every acceptance criteria for the requirement
• Dealt with data mapping issues between various source systems and staging area and data marts

Client: Confidential, Washington DC Jun 09 –Apr 10
Position: Business Analyst
Environment:TrizettoFacets4.1, Rational Requisite Pro, Clear Case, MS Visio, MS Project, SQL, Windows 2000, MS Office.

 Description: AARP is a nonprofit, nonpartisan membership organization that helps people 50 and over improves the quality of their lives.I worked on Claims processing module of the Group Approval Process (GAP). The claims processing module involved Receipt and Verification of Claim Forms (837) and Claims Attachments (275), Claims Enquiry and Response (276/277), Adjudication, Healthcare Claim Payment/Advice (835) as per HIPAA guidelines.

Responsibilities:

• Addressed the changes made to the Medicare program and created requirements mapping to that of the system requirements.
• Gathered and documentedbusinessrequirements from SMEs, user groups and vendors via workshops, interviews and surveys.
• Prepared a comprehensive Functional Requirements Document and Supplementary Specification Document (non functional) from the gathered requirements. All documentation was created using the AGILE methodology.
• Worked in Healthcare Claims Administration – Healthcare Claims Processing (837/835) includes facility claims and professional claims.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication)
•  Facilitated and managed meeting sessions with committee of SME's from various business areas including Benefits Administration, Health Claims Group, HIPAA Administration, Health Policy and Program Evaluation Team and Data Management Group.
• Created Functional specifications for the 834 enrolment files with their changed benefits in the Medicare program.
• Participated in entering, tracking system defects in Rational Clear quest.
• Submitted change requests and worked with change request records in Clear quest.
• Provide technical and procedural support for User Acceptance Testing (UAT).

Client: Confidential, Denver, COSep 08-Apr 09
Role: Business system AnalystEnvironment: MS Visio, Windows, UNIX, Microsoft Office (Word, Power Point, Excel), Rational clear quest, HL7, EDI transactions code sets

Description: Denver Health is Colorado's primary "safety net" institution, providing billions of care for the uninsured. Twenty-five percent of all Denver residents or approximately 150,000 individuals receive their health care at Denver Health. One of every three children in Denver is cared for by Denver Health physicians. I was involved in making changes to the existing payer system used for processing claims. Inclusion of the ICD code and billing code were also a part of the project to assign specific code to the disease injury to make it more consistent and precise to that of the provider's information as a part of the claim process.

Responsibilities:

• Developed and executed strategic initiatives and programs to enhance existing and Medicare claims processing functions in support of corporate initiatives and requirements.
• Working knowledge inICD 9ANSI Health codes HL7 in the claims environment for inpatients and outpatients, reviewed the implementation of the changes made in the systems as per the formats and compliance for EDI usage.
• Used EPIC software for tracking and updating the claim report project report and provided guidance in the investigation and final disposition of complex claim matters from Executive Senior Management through JAD sessions for analysis and design.
• Used the RUP methodology and related processes for software re-engineering process. Monitored claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and
• Involved in writing USE cases and prepared the Business Requirements Documents for various requirements collected from the business users. Used MS Visio and UML for generating class diagrams and activity diagrams.
• Wrote requirement document forData Extraction, Data Analysis and Loading process of collected data as a part ofdata mapping procedures.
• Reviewed and implemented Test Plans and Test Cases based on user requirements and functional requirement specifications. Performed Functional & Integration testing and defect tracking and prioritizing defects and for enhancements after base lining the requirements. Reported to team lead and managers in weekly and monthly basis.
• Involved in Change Management to record changes assessing the impact, benefit and risk of proposed changes, developing business justification and obtaining approval, managing and coordinating change implementation, monitoring and reporting on implementation, reviewing and closing

Client:Confidential, Middletown, NY Jun06-Aug 08 Position: Business Analyst Environment: Windows 95/98/NT, UML, Use Case diagrams, Rational Rose, MS Visio, MS Project, SQL Server, RUP, HTML, Win Runner, Test Director

Description: The Project was to enhance and integrate Commercial off the shelf (COTS) web based Electronic Health Record (EHR) NextGen 5.5 Software system and provide a better approach to documentation than conventional, paper based system. This software system increased access, eliminated illegible handwriting related errors, improved quality of care and security, reduced documentation expense and mitigate malpractice liabilities. The main features in this software include Powerful Search, Virtual Sticky Notes, Encounter based documentation and Template texts. Specialty modules include Allergy, Cardiology, General Medicine, Pain Management and Pediatrics

Responsibilities:
Responsible for interacting with client for requirements gathering, analyzing requirements, and creating detailed specifications

• Engaged in analyzing requirements, identifying various individual logical components, expressing the system design through UML diagrams
• Facilitated group discussions to elicit requirements in Joint Application Design (JAD) sessions by communicating with internal users and stakeholders, documented scope definition, functional specifications and created User Interface prototypes.
• Worked in close collaboration with the Project Manager andbusinessusers to gather, analyze and document the functional requirements for the project.
•  Prepared functional requirements and non-functional requirements based upon the approvedbusinessrequirements by following UML processes and standard procedures for developing use cases, use case diagrams, and other supporting documentation.
• Analyzed plan requirements and then contributed further defining the plan requirements with their Project Manager. Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements .
• Participated in the bug review meetings, Updated requirement document as per business user feedback and change in functionality of the application.
• Actively participated in status report meetings & interacted with developers to discuss technical issues.
• Designed, test, and customized EMR templates, documents and crystal reports
• Compliant processes like HIPAA(4010)/EDI formats and accredited standards like ANSI
• Developed and executed SQL queries on claim records to validate reporting
• Assisted client in developing content and training materials; recommended enhancements and identified new business requirements ensuring appropriate documentation
• Responsible for addressing, diagnosing, and resolving issues that arise on a day to day basis for the team. Also responsible for documenting the causes, analysis and final resolution to the issues/errors.
• Worked effectively with physicians, nurses, and engineers to solve problems related to EMR, EPM, and ICS to make software more user-friendly to staff and doctor
• Provided status report to Project Manager and assisted with monitoring the timely completion of scheduled tasks and escalating risks across the project lifecycle.

Client: Confidential, Butwal, Nepal Mar 05–Apr06 Position: Business s Analyst Environment: Window 98, UML 2.0, MS Visio 2000, MS Project 2000, MS Office 2000 (Excel, Word, Access, PowerPoint), SQL Server 6.5.

Description: SCBN is leading commercial bank in Nepal. The objective of project was to upgrade available services so as to provide a comprehensive range of online banking services to their clients. The new services were to provide online functionality like account information and balances, bill payments, fund transfers, deposits, and recurring payments and check management.

Responsibilities:

• Responsible for gathering requirements and specifications, project planning and identifying the resources and implementation of the project.
• Implemented and followed the Waterfall methodologies throughout the SDLC while working with multi-functional teams in gathering and analyzing the business requirements and convert it to FRS and created business process models from the requirement specification.
• Facilitated Joint Application Development (JAD) sessions, conducted surveys, and interviews to identify business rules and end-user's requirements and then documented it in a whitepaper that can be reviewed and understood by both business people and technical people.
• Utilized RUP (Rational Unified Process) to create use casesactivityclass diagrams and workflow process diagrams.
• Attended daily SCRUM and guided QA and IT Developer regarding the defects.
• Performed the analysis of the earlier systems, generated a detailed requirements document describing new system architecture through use cases diagrams and activity diagrams using MS Visio.
• Authored data flow diagrams, sequence diagrams andbusinessprocess models.
• Developed a logical Integration model detailing the flow of information through the various components, including definition of external and internal message contents.
• Conducted requirement workshops among all project stakeholders to verify and validate the business requirements in UI designs.
• Participated in the daily status meetings to discuss defects with developers, users and the product managers.
• Supported the Program Manager in balancing project goals and business needs.
• Worked in management information system department on reporting compliance, security and privacy issues.
• Provided status updates on progress including percent tested, percent of tests blocked, percent of tests remaining.
• Facilitated and managed meeting sessions with key personals from variousbusinessareas including financial executives, regional directors and contract management teams.

References available upon request