PROFESSIONAL SUMMARY

Healthcare Business Systems Analyst

• with 8 years of experience in HealthCare, PBM and IT based Industries.
• Expert in documenting the Business Requirements Document BRD , developing the UAT Plan, assisting in Post implementation activities.
• Expert in creating Use Cases, Activity Diagrams, Process Flows using MS Visio and UML concepts.
• EDI Operating Rules Mandates: experience working with rules 350, 360,370, 380 and 382.
• Worked with a tool set for creating crosswalk mapping rules and business rules to convert ICD - 9 to ICD-10. Utilized CMS GEMs General Equivalency Mapping crosswalk mapping file.
• Experience with HIPAA ANSI X 12 4010/5010 and NCPDP transaction sets: 270/271, 276/277, 834, 835, 837 Professional Institutional claims .
• Excellent understanding of HIPAA 5010, ICD -10 initiatives and MITA 2.0 Medicaid Information Technology Architecture .
• Web Portal Development worked in the development of a web portal used by providers and members to view referral information.
• Highly experienced in performing Feasibility Studies, Impact analysis, GAP analysis and Risk Analysis.
• Expert at tailoring PMBOK processes to specify project requirements and at integrating PMBOK processes with SDLC processes for maximum quality.
• Successful as a team player to work in conjunction with other DBA's, testers, developers and other team members in validation and testing complex scenarios and projects to maintain Quality Standards for Project.
• Expertise in working with Claims NASCO, Facets, FEP, Provider Portico, Enrollment, benefits and Vendor Management Business Areas.
• Expertise in analysis of healthcare claims, use of ICD 9 diagnosis codes and CPT codes.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Experience in conducting User Acceptance Testing UAT and documentation of Test Cases.

TECHNICAL SKILLS

• Skill Sets
• Description
• Programming Languages
• C, C, XML, SQL.
• Data Base
• MS Access, Oracle, DB2.
• Operating Systems
• MS-DOS, Windows95/98/NT/2000/XP.
• Software
• MS Office Suite Word, Excel, Access, PowerPoint Outlook, MS Visio, Share point, Rational Requisite Pro, Adobe Acrobat, Citrix, TRMS, Toad, Ultra Edit
• Automation Tools Standards
• EDI standards, HIPAA Compliance, Medical Claims clearinghouse,
• ASC X12 cross industry standards, ANSI
• QTP, Test Director, Quality Center, CAQH
• Methodologies
• SDLC, PMLC, Six Sigma.

WORK EXPERIENCE

Confidential

Business Analyst / EDI Analyst

EDI Operating Rules Mandates: Continuing to build on Phase I and Phase II CORE Committee on Operating Rules for Information Exchange Rules, CAQH Council for Affordable Quality Health Care CORE determined that Phase III CORE should be extended to include rules around the health care claim payment/advice transaction to allow the industry to leverage its investment in the Phase I and Phase II CORE infrastructure rules and apply them to conducting the HIPAA-adopted ASC X12 005010X221A1 Health Care Claim Payment/Advice 835 transaction hereafter referenced as v 835 . This project will update the blue exchange EFT's Electronic Fund Transfer, ERA's Electronic Remittance Advice 835's transactions as a result of the ACA Affordable Care Act mandate and adoption of CAQH operating rules relating to ERA/EFT.

• EFT Enrollment: CareFirst must ensure that its trading partners TP's enroll providers in EFT in compliance with the requirements in Rule 380.
• ERA Enrollment: CareFirst must ensure that its trading partners enroll providers in ERA 835 in compliance with the requirements in Rule 382.
• Performed gap analysis for EFT enrollment process and ERA enrollment process for each of CareFirst's trading partners Allscripts Payspan, RealMed, RelayHealth Payspan, and Emdeon .
• Walkthrough the Gap Analysis document for EFT Enrollment form, EFT data element description, ERA Enrollment form and ERA data element description with each trading partners and provide direction for changes that needs to be implemented to be in compliance with CORE rules.
• Bridge between CareFirst, TP's and CAQH, asking questions to CAQH for changes those are needed to implement per CORE rules and communicate information back to CareFirst and TP's.
• Associated in JAD session in development of BRD Business Requirement Document to achieve goal as per CORE rules requirement.
• Associated in JAD session in development of IAD Interface agreement document for EDI Vendor EFT Enrollment WEB Service.
• Involved in development of future state design for EDI Vendor EFT Enrollment WEB Service.
• Communicate and a walkthrough change designed by CareFirst to each TP's EDI Vendor EFT Enrollment WEB Service by providing enough information including IAD so that TP's can execute changes on their end.
• Responsible to update Submitter Guide per CORE rule requirement - document that is intended to provide information to trading partners about the submission of standard transactions to CareFirst.
• Involved in development of IAD for submission: Trading Partners need to submit 999 acknowledgements to CareFirst Consolidated Gateway CGW for the received 835 batches over AS2 connectivity.
• Communicate and a walkthrough change designed by CareFirst to each TP's submission by providing enough information including IAD so that TP's can execute changes on their end.
• Reviewed Test Cases and raised defects for 380 EFT Enrollment and 382 ERA Enrollment.
• Bridge between CareFirst CGW team and trading partner for their Testing effort on both EFT Web Service and submission.
• Research on Magic Tickets and provide proper solution to providers or trading partner.
• Research missing remits per Trading Partner/Provider request and respond them by proving proper solution for it.
• Research for claims that are not being paid per Provider request, provide them denial reasons/errors.
• Responsible for finding US 95 error file, ran query to get correct files for Facets, updated Facets run Log file with File Name, Provider name and BPR Amount and keep tracking of it on daily basis by making sure corrected file goes through.
• Responsible for setting up provider interested in direct electronic claim submission enrollment and notifying them via email once it is ready. Payerpath powers CareFirst direct claims product.

Environment: Toad Oracle, Citrix, Ultra edit, MS Office Suite Word, Excel, Access, PowerPoint Outlook, Portico, NPPES, TRMS, Payerpath, Share Point.

Confidential

IT Business Analyst

Amerigroup is leading Confidential and honored Fortune 500 Company having 2 million members across the country. Amerigroup offers health care services through four government programs that target different segments of the country's low-income population: Medicaid, the Children's Health Insurance Program CHIP, Family Health plus FHP and Medicare in different states Florida, Georgia, Louisiana, Maryland, Nevada, New Jersey, New Mexico, New York State, Ohio, Tennessee, Texas and Virginia .

• As part of Enterprise Reporting team, I was responsible for generating various healthcare reports as per Kansas, Maryland and Florida state requirements.
• Wrote meeting minutes for KS team.
• Created reference guide for PR2 Provider Enrollment report.
• Worked on Ad-hoc for reports those were urgent and at risk in terms of deadline to state.
• Worked on long term solution for reports those are monthly, quarterly and annually.
• Created KS Specialty crosswalk for Provider Network Report for developer.
• Gathered requirement from Business Owner and Subject Matter Expert.
• Documented requirements for different regulatory and operational reports in designed BRD format.
• Set up various meeting for creation of design and development with business owner, users and Project Managers, Project Sponsors.
• Assigned task to development team and was responsible for monitoring and control of project.
• Created CNR Change Notification Request and communicated with all stakeholders in each iteration of project.
• Created data mapping per Facets for requirement and developed functional requirement as per BRD.
• Tested output provided by development team as per business requirement and created test cases.
• Communicated with Business owner and Project Sponsors for UAT sign off.
• Deployed approved UAT report to production and verified data in production servers and closed CNR.
• Researched on Provider, Member, Claims, Appeals and Grievances data in Facets and used it meaningfully by joining different tables of Facets for reporting purposes.
• Researched on vendor data for providers like Pharmacy, Laboratory, Vision, Dental etc
• Worked on Provider Network report Geo access and non Geo, Provider Access Payment Report, Claim report, Appeals, Grievances and Complaints report and FQHC and RHC provider report.

Environment: Microsoft SQL server Management Studio 2008, JIRA, Ultra edit, MS Office Suite Word, Excel, Access, PowerPoint Outlook, Facets front end and back end, Vendor Table, ODW, ERDB, PEGA, WebEx, Share Point.

Confidential

Business Systems Analyst / EDI Analyst

• As part of the EDI team was responsible for Claims balancing 837, Remittance balancing 835, 837 Compliance issues, 835 Compliance issues, Provider Setup for Electronic Claim Submission daily.
• Compared the Daily Activity Report DAR files claim counts and dollar amounts to the received claim count and dollar amounts.
• Checked for compliance, PPE syntax check and sent respective claim adjudication systems, Facets, NASCO and FEP after reviewing claim counts and dollar amounts.
• Reviewed DAR files and claim files received trading partners ACS, Allscripts, RealMed, Emdion and RelayHealth and checked for anomalies.
• Compared the claims received from trading partners with the CareFirst Consolidated Gate Way CGW internal team to make sure that all ISA number are matching. Provided the feedback to trading partners for missing files.
• Compared the claim counts and dollar amounts by platform with the received Gateway claim counts and dollar amounts.
• Checked for the Compliance error for 837 I/P, corrected errors for making sure they pass compliance and finally released to production.
• Responsible for checking if provider is enrolled to receive remit electronically, if not then determine what is the reason and provide feedback to trading partner.
• Compared EDI Gate way data for 835 with the remits sent for FEP, FACETS, DCNASCO and MDNASCO. Calculated the difference between 835 and EDI Gateway data, resolved, reported any differences by Platform.
• Responsible for checking compliance error for 835. Responsible for creating new X12 file for transaction sets those are having compliance issues with remittances, correcting errors and making sure they pass compliance and finally released to production.
• Maintained repository reports for NASCO and Facets, with details of ISA Control numbers, GS Control numbers, ST Control numbers, Total Dollar Amounts, in date, Error, Status, and Remit release date to Trading Partner.
• Responsible for setting up provider interested in direct electronic claim submission enrollment and notifying them via email once it is ready. CareFirst direct claims product is powered by Payerpath.
• Responsible for finding US 95 error file, ran query to get correct files for Facets, updated Facets run Log file with File Name, Provider name and BPR Amount and keep tracking of it on daily basis by making sure corrected file goes through.
• Received ACS Repots and updated the Remittance and Claim report daily and stored on share point.

Provider call Deflection project:

• The purpose of the project was to identify and implement enhancements to CareFirst self-service tools used by provider community across all ASUs Administrative service unit . The goal of the ASUs was to realize a 10 to 45 reduction in calls across the ASUs in 2012 as compared to 2011 volumes. Adding the new remittance function to the Provider Portal will support a more efficient inquiry experience for providers using CareFirst Direct CFD on the Provider Portal.
• Researched remits Facets, Nasco, Care and Flexx required from Provider Call deflection project team and provided them correct remit.
• Responsible for comparing remit with provider portal, checked for the problems in portal and notified the Project Manager for portal development.
• Responsible for Comparing different BCBS plans for Remittance, with their number of paper claim count received in 2011 versus electronic claim count received in 2011 and their projection for 2012. Compared their remit strategy to understand the output of the process.

Environment: Toad Oracle, Citrix, Ultra edit, MS Office Suite Word, Excel, Access, PowerPoint Outlook, Portico, NPPES, TRMS, Payerpath, Share Point.

Confidential

• Worked with the BCBSSC proposal writing team to document the Project Management strategy for Medicaid Management Information System MMIS replacement opportunity for the state of South Carolina.
• Wrote the Project management Strategy which included development of scope management, schedule management, quality management, risk and issue management, communication management, change management, operation management.
• Responsible for incorporating proposal strategies, themes/discriminators, technical/management features, benefits and other material into assigned sections.
• Participated during storyboarding and through blue team, red team and final draft white gloves when the core team took over.
• Interacted with team members from companies such as Wipro, Infocrossing, Healthation, and Carolinas Centers for Medical Excellence for work related assignments.
• Responsible for working with the Technical Manager to leverage the review processes to validate approaches and fulfillment.
• Responsible for collecting and structure team members comments, and leads the review debriefing.
• Lead the team of three Business Analysts and provided status to Project Manager daily.

Environment: MS Office Suite, MMIS, SharePoint, MS Project.

Confidential

Business Systems Analyst

ICD10 HIPAA 5010 EDI Modernization Project: HIPAA 5010 is one of the prerequisite for the successful implementation of the ICD10 codes .The deadline for the healthcare entities to be HIPAA 5010 compliant is 01/01/2012 .The healthcare entities will make sure that their EDI and Auxiliary system are able to handle the ICD10 codes. The scope of EDI Gateway Modernization project is to migrate the current EDI Gateway environment to a new platform. This new platform/ environment will set up a good base for HIPAA 5010 ICD 10. The current version of the mapping tool cannot support level 4 edits and higher. The current version of GENTRAN is not HIPAA 5010 compatible. To support the future strategic projects of BCBS, there are requirements needed to change the business process flows and IT architecture.

• Conducted ICD 10 Impact Assessment of the various streams such as Health Care Management UM, DM, CM, QM, Benefits, Mandates and Medical Policy, Claim Processing NASCO ITS Data Storage, Provider Contracting and Reimbursement.
• Documented the Current State, Future state and performed Gap Analysis using Six sigma tools such as FMEA.
• Prepared Vendor communication strategy and plans for the ICD-10 awareness and readiness.
• Prepared Enterprise level ICD-10 Training curriculum for the coders, claim processor and related staff.
• Worked on Gap/Impact Analysis Document for the Prescription Drug Point of Sale System.
• Worked on Gap/Impact Analysis Document for the Drug Utilization Review System.
• Met and gathered requirements from EDI services, NASCO, QBLUE, HIPAA 5010 team, E-Services and Web services team.
• Worked with the various NASCO subsystems such as Pricing, Adjustments, HIPAA repository, Claim Scrubbing, ITS Host Home, Payment Resolution, EEC Electronic Error Correction, and Payment System.
• Created Gap/Impact Analysis Document for changes of the EDI Transactions 837, 835, 276/277, 270/271
• Documented BRD Business Requirements Document, RTMs and getting them sign-off from all the stake holders.
• Reviewed TRDs with stake holders and commented on them to get them updated from the Implementation Vendor the requirements to reflect the business need of the stake holders.
• Reviewed and raised defects on test cases from SDG team.
• Documented Future state Project Definition Documents PDD and got signed off from stake holders.
• Documented BRDs for 834,835, 835 reports and screens, 276/277 reports and screens.
• Worked as a UAT Testing Lead and coordinated with SMEs in defining, designing, conducting and evaluating results.
• Defined Transition and Post Production Operational Support Plan.

Environment: MS Office Suite, SharePoint, MS Visio

Confidential Business Analyst

MMIS System Enhancements: The project consisted of several Service requests that were for the enhancements to Medicaid Information System. These enhancements includes Provider Enrolment through new web portal system PEP, LTSS Long Term service and support Provider enrollment, automating validation for claims/encounters, PCCM Enhancements, CMS interfaces, Medicaid Advantage Testing and Support.

• Gathering and documenting of business requirement to support key enterprise projects and project team members.
• Identify and promoting process improvement opportunities for gathering requirements.
• Responsible for creating and maintaining Requirement Traceability Matrix RTM and Customer Requirement Template CRT for each of the assigned project.
• Involve in development of Request for Proposal RFP .
• Scope and access each project impacts from each Grouping and perform Risk Analysis from Subject Matter Experts.
• Assisted call center for escalation and researching issues for claims adjudication and payment.
• Accumulating and analyzing provider, member, claims and data related to HMO.
• Update and create/develop Use Cases based on Project impact.
• Update and create process flow diagrams and sync up those diagrams with IT team for accuracy and maintain for future references.
• Perform GAP analysis between the current system and future system to make sure all the data elements to perform the business have been taken care of.
• Conduct JAD sessions with Business and IT Matrix partners to support all the business needs and requirements.
• Facilitating review of complete business requirement with stakeholders, business functional and IT partners in order to secure buy-in-sign-off requirement deliverables.
• Supporting and development of Functional Requirement and system design to ensure that they meet defined business and project objectives.
• Responsible to Support change controls of projects that comes in during and/or after the project being implemented.
• Make sure all the internal Management as well as external Client facing reporting requirements are met during detail requirement and validate that reporting requirement meets the project and business needs.

Environment: RUP, Visio, MS Office suite, Java, JavaScript, HTML, Oracle, MS project, QTP, Mainframes, SQL

Confidential

Business Analyst

Benecard is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. PBM Prescription Benefit Facilitator PBF is a web based application and provides a fully integrated solution that facilitates the end-to-end business process required for the Pharmacy Benefit Management service provider. The system uses the rule engine to govern the claim adjudication process. The PBM Services staff is the primary users of the system. It provides user interface to their internal and external Users to maintain updated client/customer and provider information. PBF can interface and integrate with the external sources for the information related to the Pharmacy, Prescriber, Client and Drug files.

• Responsible for gaining a good understanding of User needs and accurately representing them in a well-documented software functional specifications document.
• Gathered Business Requirements, Interacted with the Users, Designers and Developers, Project Manager and QA Team to get a better understanding of the Business Processes.
• Involved in creating Project Management Documentation, Fallowed PMBOK Standards.
• Interacted with the End-Users by interviewing them, by preparing appropriate questionnaire to better understand end-user needs and the business process.
• Followed a structured approach to organize requirements into logical groupings such as requirements for Customer, Client, Group, Member, Prescriber, Pharmacy, COB, CRM, AR/AP and Reporting that critical requirements are not missed.
• Involved in creating Business Process Documentation. Identified Use Cases from the requirements. Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams using MS-Visio.
• For Project management purpose worked on Microsoft Project, used Microsoft Share Point for maintaining the updated Documentation.
• Microsoft Office Outlook, Word, Excel, Visio, Access at various phases of development for documenting the requirements.
• Analyzed and optimized the process, Prepared Business Requirement Document and managed requirements using Rational Requisite pro.
• Worked with project teams in preparing software requirement specifications SRS, software design documents SDD, user interface design.
• Facilitated JAD sessions with business and technical units to fine tune, prioritize and detail requirements and use cases.
• Identifying and understanding the business critical areas from the user perspective.
• Managed change of the requirements and associated requirements to other requirements for traceability using Enterprise Architect.
• Involved in risk-management process whereby identified critical areas of business risk and modified the business process to reduce the same.
• Involved in drawing data flow diagrams and process flow diagrams using MS Visio for the Claim Adjudication module.
• Worked on 4010 HIPPA Electronic Data Interchange EDI Transactions, HIPAA X.12, 837 medical claims, 835 Electronic remittances 270/271 Eligibility inquiry and response,, ICD 9 Codes.
• Identified Business Rules, involved with building a rule based application that automate fine-grained, variable decisions used for Claim Adjudication.
• Involved in design the application for processing of CMS Claims for Medicare Part D, Medicare Part C, and Medicaid with complete billing and reporting.
• Involved in gathering reporting requirements from the business users.
• Involved in the development of Mail order system associated to this PBM application.
• Involved in generating Test Plans and Test Specifications as per Business requirements.
• Involved in conducting Manual and Automated testing at various phases of the project development.
• Prepared test data for positive and negative test scenarios as per application specifications and application requirements and wrote test plans.
• Participated in the bug review meetings, updated requirement document as per business user feedback and changes in the functionality of the application.
• Organized meetings to discuss outstanding issues with QA team and developers.
• Involved in User Acceptance Testing.
• Coordinated with the development team in documenting End User Manual.

Environment:, DB2, XML, UML, Informatica, Web 2.0, Web Portal, Data Warehouse, PMBOK, Microsoft Share Point, HIPPA, PEGA, Rational Unified Process RUP, Rational Requisite pro, MsVisio.

Confidential

Junior Business Analyst

Department of Health and Human Services, New Jersey's state wide automated system for the welfare programs under title IV of the Social Security Act Child/Spousal Support, Medical support, Foster Care etc and is federally certified. It has interfaces with other welfare systems like AFDC, Medicaid, Food Stamps, Comprehensive Claims Systems, etc. The project is to design, develop and implement extensive software changes in TANF Temporary Assistance for Needy Families program and mandated by the Provisions of the federal Welfare Reform Enactment's PRWORA that are to be audited and certified by DHHS in a time bound manner.

• Involved in requirement gathering and analysis by conducting group interviews with users.
• Involved in documentation and developed URS and FRS.
• Worked in the RUP framework in requirements analysis management and used standard artifact and tool mentors suggested in RUP.
• Developed Use Case Diagrams, Activity Diagrams and Functional Diagrams using Visio.
• Interaction with the help desk team, production team and design teams and involved in the change requests and problem report documentation.
• Lead the JAD session with different interacting department managers and refined the requirements.
• Worked with change control board in the implementation of change and extensively interacted with case workers and managers, conducted User group meetings.
• Involved in GAP and Risk Analysis and made recommendations in the implementations of certain security features.
• Responsible to work with software engineers and developers to outline the process and mappings to load the data from the flat file to the database tables.
• Used SQL Developer for accessing the database writing SQL queries.
• Involved in testing of Internet enabled Java/Application server based system which enabled the client server system to interact with Mainframe/DB2 database.
• Assisted in Designing of test scripts, goals, objectives for the applications and executed them.

Environment: RUP, Visio, MS Office suite, HTML, Oracle, MS project, QTP, Mainframes, SQL Developer