SUMMARY OF QUALIFICATIONS:

• Above 8 years experiences as Healthcare Business Analyst and Clinical Research Associate with extensive experience in healthcare, pharmaceutical and health insurance industries.
• Sound knowledge of Health Insurance and Portability and Accountability Act HIPAA .
• Strong knowledge and experience in Healthcare industry. Functional knowledge of Medicaid Management Information System MMIS , FDA, ICH-GCP guidelines, rules and regulations.
• Excellent writing and analytical skills in preparing business requirements, system requirement, functional specifications. Hands on experience with transactions such as 837 I, P, D , 834, 835, 270, 271 and 276.
• Exposed to using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, reimbursement methodology.
• Implemented various HIPAA codes 270 and 276 used for Billing and Eligibility purposes of patient records.
• Have strong experience in requirements gathering by conducting interviews with end users
• Comprehensive knowledge of Software Development Life Cycle SDLC , having thorough understanding of various phases like Requirements, Analysis/Design, Development and Testing as well as methodologies like Waterfall, Agile etc.
• Exposure in Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10 Conversion for CM Diagnosis Codes and PCS Procedure Codes .
• Experience in conducting UAT User Acceptance Testing and documentation of test cases, ability to communicate both on a business and technical level and experience in coordination with business and technical resource
• Adept at creating and transforming business requirements into functional requirements and designing business models using UML diagrams Context, Use Case, Sequence, Activity diagrams in MS Visio and Rational Rose. Good Control on MS Office suite, MS Visio and MS Project.
• Organized many Joint Application Developments JAD sessions and Joint Requirement Planning sessions JRP , walkthrough, Interviews, Workshops and Rapid Application Development RAD sessions with end-user/clients/stake holders and the IT group.
• Excellent presentation skills with MS Power Point, which was extensively used in different JAD sessions and to track progress. Communication ability with prospective vendors.
• Assisted the project manager with activities like development of business processes, effort estimation, resource management, issue/risk analysis, milestone tracking and associated documentation.
• Extensive experience in gathering, managing and documenting business requirements and functional requirements, communicating effectively with upper management, senior BAs, developers and QA engineers. Well versed in different management scenarios like Change Control, Quality Assurance, Defect Tracking, System Integration and Scheduling.
• Processed and distributed all safety reports received from any source i.e. clinical trials and post-marketing for assigned products or studies as per ICH-GCP guidelines, regulatory requirements, company Standard Operating Procedures SOPs , policies and procedures.
• Knowledge of FDA and ICH guidelines and product labeling in performing initial case assessment for seriousness and expectedness. Involved in evaluation and assessment of incoming case reports and source documentation for completeness, accuracy, legibility and consistency of information.
• Knowledge of drug development process, applicable clinical trial safety regulations and post marketing regulations.
• Extensive experience in creating expedited and non-expedited individual case safety report, periodic and annual safety reports and submitting to regulatory authorities, partner companies and other trading partners as needed to ensure compliance with regulatory and company timelines.
• Proven expensive ability to evaluate clinical, epidemiologic data and common data processing software MS Word, Excel, PowerPoint, Business Objects
• Excellent track record for meeting deadlines and submitting deliverables on time.
• Excellent documentation, communication and interpersonal skills.

TECHNICAL SKILLS:

• Operating System: Window 2000 / XP / Vista/ 7.
• Languages: SQL, SAS.
• Application Management Tools: Rational Rose, Rational Requisite Pro, Clear quest, Clear case.
• Databases: MS Access, MS SQL Server, MedRA, WHO-DD.
• Microsoft Applications: Word, Excel, PowerPoint, SharePoint, SPSS.
• Workflow Tools: MS Visio, MS Project, LTC400/AS400, Lab-View, Mat-Lab.

Confidential

Business Analyst

Responsibilities:

• Analysis on the Business requirement document BRD structure as well as focusing on the completeness and clarity of the requirements.
• BRD analysis was classified into three categories- not applicable for enterprise testing, ready for scenario development and additional information needed to complete the development of testing scenarios.
• Review and analysis of BRD involved in a number of artifacts which will continue to be a working document to record the progress and traceability of test preparation, testability analysis report and detailed business requirement analysis checklist.
• Involved in Functional Area Analysis to report the overall status of projects. It reports the key summary data as well as the current status of open question and missing information for each project. It enabled QA to review status of projects based on a number of criteria such as Impacted Area, Open Questions, Information required and Functional area.
• Perform a baseline assessment 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.
• Have strong experience in requirements gathering by conducting interviews with end users.
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Identified risks, problems, requirements and concerns to comply with ICD-10 changes.
• Highly involved in understanding of department workflows and process flows with respect to applications
• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
• Re-Organized the collected data and prepared documentation for implementation.
• Performed impact analysis on applications for deadliness of ICD-10 conversion.
• Key finding concerning the business requirements and supporting artifacts analysis were categorized into the following areas: QA status, Testing complexity and Area of impact.
• Used Rational Clear Quest for defect tracking and change management request and reported them. Responsible for writing UAT test plan, scripting the test cases and performing UAT.
• Key impacts documented in the analysis focused on the financial integrity, benefit neutrality and operational stability.
• Coordinated and conducted system requirements sessions JADs with business Owner/stakeholders/SMEs as well as design/development teams. Worked with business area SMEs/analysts to develop and finalize test plans/scripts/use cases. Analysis of key business requirements and assisted in the development of Business Requirement BRS , Functional Requirement FRS and System Requirement Specification SRS .
• Worked on Medicare Advantage A, B, C , Medicare Part D MA-PD , Medicaid Options Under 65 and Over 65 and Managed Care Care, Disease and Case Management and also in Insurance regulations and Claims Processing and claim scrubbing in HMO, PPO, Medicare and Medicaid.
• Met the deadlines and scheduled day to day meeting sessions.

Environment: MS Office, Excel, PowerPoint, SharePoint and Visio.

Confidential

Business Analyst

The project was about making a business assessment to determine readiness of Tenet to comply with the new standards mandated by the Health Insurance Portability and Accountability Act HIPAA 1996. The assessment process consisted of a business-impact assessment, compilation of results, gap analysis, and developing business case. The business-impact assessment involved a series of interviews. The results of the business-impact assessment were compared with the related HIPAA standards to determine the current level of compliance and used to develop an action plan for approval by the project steering committee.

Responsibilities:

• Facilitated interview sessions to identify business rules and requirements and then documented them in a format that can be reviewed and understood by both business team as well as and technical team.
• Created targeted Questionnaires for SMEs to gather requirements.
• Understood and articulated business requirements from user interviews and then converted requirements into functional specifications.
• Conducted JAD sessions with the system owners and different team leads to analyze requirements.
• Created Business Requirement Document, Functional Requirement document and Summary Reports.
• Conducted analysis of HIPAA compliance and took part in discussions for designing the healthcare transactions to be HIPAA 5010 compliant.
• Used detailed knowledge of the application features and functionality to assess the scope and impact of business needs throughout the analysis and completion of the enhancement specifications.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure, features and functionality with the new business design using the As Is and To Be methodology.
• Conducted business-impact assessment and the results were compared with the new HIPAA 5010 standards to determine the current level of compliance and developed an action plan for approval by the project steering committee.
• Developed business case which included results of the business-impact assessment, gaps identified, alternative solutions, risk assessment, preliminary work plans, resource requirements, and a budget for completing the initiative.
• Identified gaps between Tenet's current policies and procedures and new HIPAA 5010 compliance and developed an action for the migration process.
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships.
• Identified solutions to close gaps in HIPAA compliance.
• Followed Agile methodology and participated in the daily scrum meetings.

Environment: Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Project, Microsoft Visio, Rational Rose, Rational Requisite Pro, MS SQL, Adobe Captivate 3.0 and Windows XP.

Confidential

Business Analyst

Coventry Health Care serves more than 5 million members in all 50 states across a full range of products and services including group and individual health insurance, Medicare and Medicaid programs, and coverage for specialty services such as workers' compensation. The system is Facets electronic billing based and performed appropriate data extractions methods to be employed to map all the data and made available for data analysis and reporting purpose.

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Facilitated JAD sessions for Requirement Validation with HPA to gather requirements for the new MMIS.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Analyze, and document business and functional requirements via uses cases for Medicare billing transaction-based middleware/database layers with SOA XML.
• Validating the EDI 837 claim billing professional, institutional and dental claims 835 remittance advice or payment claims adjudications.
• Prepared client process maps for the consumer, broker, employer and provider transactions for the Facets process.
• Designed and developed Use Case Diagrams for the Facets process modules.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X10 Transaction, Code set and Identifier aspects of HIPAA.
• Documented and tracked requirements in Mercury Quality Center.
• Designed and implemented HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction. Populated ICD-9, NDC Disease code sets as per the standards. Experience with transaction sets 835, 837, 270, 271, 276, 277 and 5010.
• Provided suggestions and ideas more from a strategic and long term perspective.
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Worked on EDI transaction 835 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Incorporated HIPAA standards, EDI Electronic data interchange , transaction syntax like ANSI X10
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Involved in analysis for wide range of Six Sigma and Web-based initiatives, including user requirements.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database
• Analyzed and Documented Business Requirement Document BRD , Functional Specification Documentation, and System Requirement Documentation, using UML methodologies
• Conducted meetings to understand the workflow, their processes and assisted in gap analysis to derive requirements for existing systems enhancements.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Create technical design documentation for the data models, data flow control process, metadata management.
• Logged defects into QC while doing Functional Testing and followed through the process until the defects were closed.
• Reviewed the Defects entered by the QA team and prioritized the defects and assigned them to the development team
• Prepared UAT Materials, including the UAT Process, UAT Test document which would include step-by step process for UAT as well as all the tests that would cover all requirements.
• Worked extensively with the QA team for designing Test Plan and Test Cases for the User Acceptance Testing.
• Prepared system Test Plan and scenarios for Test Scripts.

Confidential

Business Analyst/Data Analyst

The project was to develop a customized pricing solution for the organization's complex need and also to develop a Provider Network Management solution for managing complex contractual negotiations with the providers. CareSource was using Trizetto's Facets 4.31 as their health plan administration system and the Organization was looking for a pricing solution and network management solution to meet their growing customer demands for faster processing and simplifying administration.

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Working within a growing knowledge of X12 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Provided full life cycle support for company's Facets enhancement to Facets e2 Workflow and Network Management Suite with Pricing Modeler and Network Modeler application--including Business Requirement gathering, Functional Design, Technical Design, and Production Support documentation for multiple outgoing interfaces.
• Used Facets 4.31 to receive, store and send HIPAA-standard transactions 835, 837, 270, 271, 276, 277 and to administer HIPAA privacy rights.
• Participated in Facets Table data modeling planning, designing, implementation of the data warehouse and conducted testing by developing complex SQL queries.
• Mapped provider data from source to target Facets 4.31 data layout for the claims and benefit configuration.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process
• Worked with the QA team in testing the upgraded system for data retrieval, using complex SQL queries.
• Validate the Business-to-Business data exchanges between data exchange partners validate the internal processing of the MMIS, or other transaction processing system.
• Involved in meeting with Provider communities to discuss the conversion of the Legacy System to New MMIS system.
• Conducted a requirements study for replacing their Order Entry and Billing applications including a review of their Customer Service operation, web sales, and other e-commerce needs.
• Identified needed modifications for upcoming ICD9 directives from the then available documents from World Health Organization, and CMS
• Analyzed CMS comparison documentation highlighting changes of 4010 format and ICD9 diagnosis and procedure codes.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 P.I.D to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Worked in all the different processes of Claims processing from Claim Online editing /processing /Adjudication /Payments systems
• Responsibility included interacting with the users and business relationship managers and implementing changes on the database in order to ensure approval.
• Responsible for creating different sessions and workflows to load the data to Data Warehouse using Informatica Workflow Manager.
• Worked with SQL Server and developed and ran SQL queries for data selection, cleansing and data mapping.
• Managed the transition to new development standards, procedures and processes including the introduction of UML, Rational Products including Rational Software Architect, ClearCase and ClearQuest as well as the Mercury Test Suite
• Was responsible for data mapping of HL7 messages into relational database.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Assisted QA testing in formulating the test plans, reviewed QA test plans for appropriate test coverage and managed the Change request documentation for Change management processes.
• Developed business process models in RUP to document existing and future business processes.
• Used senior level SQL query skills Oracle and TSQL in analyzing and validating SSIS ETL database data ware house processes.
• Worked with business and system modeling tools such as Data Flow Diagrams DFD , Process Models, Entity Relationship ER Diagrams, and Use Cases
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team

Confidential

Business Analyst

The HI-Exchange Project dealt with development of an online health information exchange HIE and a secure web portal to enable authorized Franklin Square Hospital providers to have fast and easy access to patient's electronic health record. The HI-Exchange web portal features EMR functions and Integrated Clinical decision Support tools for better care management. The project dealt with development of a Health Care Cost Containment System and implementation of an automated inter-operable web application that tracks patient medical history and health care plans via Viewer application and Electronic health records. The Viewer/EHR system provided online access to mobile patient records and improved communication in public health.

Responsibilities:

• Prepared logical data model in the form of Business Context diagram to include various entities and attributes in order to facilitate the design of Data model in the form of ER Diagrams. Studied current information structures and data models of the current databases to better understand the design of target data source.
• Performed custom data conversions and developed custom software for risk management applications including general claims, vehicle accident and administrative tracking. Performed all data field mappings.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Used Rational Clear Quest to track required changes and Rational Clear Case to maintain different versions of the project documentation
• Modeled Business requirements into workflows to depict various scenarios of system to request RFI and RFP responses from major vendors.
• Responsible for identifying, documenting and testing the data mapping feeds from several reference data systems, to risk applications
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Intricately involved in Business Process Flow development, Business Process Modeling, and ad hoc Analysis
• Performed detailed comparative analysis of response to RFPs of vendors and Graphically Represented the recommended solutions in PowerPoint to Senior Management
• Prepared Business Context Diagram, Use Case diagrams and corresponding Activity Diagrams using Rational Rose to depict the workflows to be incorporated into the development of Pega Business Process Management BPM tool.
• Conducted Requirements walk- through with the Business Team to ensure that all their needs are met and gathered sign off on the requirements for SOX compliance after the requirements were base lined.
• Prepared and maintain Business Rules Spreadsheets BRS identifying Rules, Triggers and corresponding data fields from Legacy to target CRM application.
• Captured Data flow diagrams and formatting of the data flowing through interfaces.
• Lead the effort of Data Migration from disparate data sources into normalized data to eliminate redundant information and organizing the tables to easily maintain the table structures.
• Prepared Test Cases based on base-lined Requirements Document, prepared Requirements Traceability Matrix and provided Performance Testing Requirements. Worked very closely with the Test team to Test all iterations during the Testing Phase and documented all the defects.
• Facilitated the User Acceptance Testing UAT with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
• Prepared training materials in the form of User manuals by preparing step-by-step guide to all screen flows in CMS.
• Assisted in development of User Interfaces and prepared screenshots to get business's buy-in on the requirements.
• Worked with Siebel trainer to prepare training materials and conducted on-site training with Siebel to train the various types of audience like Customer Relationship Representatives CRRs , administrators and Account Managers AMs .