SUMMARY

• Over 8 years of professional experience as a Business Analyst working on design, analysis process flows etc.
• Skilled in gathering business and application requirements, Business Processes, identifying risks, impact analysis, UML modeling, and Sequence and Activity Diagrams using Rational Rose and Microsoft Visio in Clinical and Health Information Management HIM processes.
• Extensively worked on analysis compliance of ICD 9 to ICD 10 and HIPAA Health Insurance Portability and Accountability Act 4010 and 5010 EDI transactions.
• Experience with Medicare, Medicaid and commercial insurances in HIPAA ANSI X12 formats including 270/271,276/277,820, 835, 837, 997
• Proficient in authoring Business Requirement Document, Narrative Use Cases, creating Use Case diagrams, Sequence Diagrams, Activity Diagrams and other UML based diagrams using MS Visio, Rational Rose.
• Experience working in a matrix environment, enhancing UI applications, creating data sets, extracting and synthesizing data, conducting and interpreting quantitative and qualitative analyses.
• Excellent Knowledge in Electronic Medical Record EMR / Electronic Health Records EHR modules and process flow
• Extensive knowledge about the various types of health insurance programs such as : Medicaid, Medicare Part A, B, C and D , PPO Preferred provider organization , HMO Health maintenance organization
• Sound knowledge of Patient Protection and Affordable Care Act PPACA , HIX Health Insurance Exchange , Sarbanes-Oxley Act SOX , ACORD, SOPs Standard operating Procedures and forms, GMP's terms and Practices.
• Experience with claims process and adjudication in the Medicare, Medicaid Private Insurance Sectors
• Extensive Experience in all the phases of Software Development Life Cycle including: Requirements Gathering, Feasibility study, Analysis, Design, Development, Testing, Deployment and Maintenance.
• Excellent knowledge and deep understanding of industry standard methodologies like Iterative Software Development Life Cycle Process as per Rational Unified Process RUP , CMM Capability Maturity Models , ISO9000 and Six Sigma and Rational Tools used during various phases of RUP such as Inception, Elaboration, Construction and Transition. Also worked using various methodologies such as Agile Software Development, Rapid Application Development RAD , Joint Application Design JAD and Prototyping.
• Demonstrated skills in critically conducting the GAP Analysis throughout the projects in evaluating/ analyzing the existing standards and policies to determine the improvements
• Expertise in Business Modeling and UML Diagrams Use Case Diagrams, Activity Diagrams, Sequence Diagrams using MS Visio and Rational Rose.
• Strong knowledge of Business Intelligence, Data Warehousing, Data Modeling and Analytics concepts with expertise in grasping transaction flows and process management
• Expertise in Healthcare Data warehousing and BI tools SQL server Reporting/Analytical tools
• Knowledge of ITSM Infrastructure Services Management and ITIL Information Technology Infrastructure Library methods and processes.
• Expertise in reviewing Test Procedures, creating Test plans, defining System Integration Test Cases, executing Test Cases, Test Data reviewing and maintaining and executing detailed Test scripts for User Acceptance Testing UAT , analyzing bugs, interacting with team members in fixing.
• Extensive use of Mercury and Rational Tools for Functional and Performance Testing
• Expertise in Client site coordinator that involves understanding business requirements, day to day client interaction, offshore knowledge transfer KT activities, onsite status call coordination, project deadline keeping and worked as a team with business partners and end data customers
• Excellent Written and oral communication skills with ability to articulate requirements, process flows and relationships.

Computer Skills

• Languages: C, C , Java Script, SQL, HTML, WML, ASP, VB Script and COBOL
• Methodologies: OOAD, RUP, UML, SDLC, JAD, Six Sigma, CMM, RAD, SCRUM
• Databases: Oracle 10g 11g , SQL, MySQL server, MS Access,
• Tools: MS Office Word, Excel, Project etc. , Caliber, Visio, Adobe Acrobat Suite, Informatica, Rational Rose, Requisite-Pro, Clear case, Quick Test Professional, Clear quest, Crystal Report Business Objects
• Quality Management: Test Director, Quality Center, Load runner and ISO Concepts
• Platforms: Windows NT, 2000, XP , Unix, Mainframe
• Reporting Tools: Business Objects, MS Excel, Crystal reports, Cognos
• Other Tools: Clarity, EMC Documentum eRoom

Projects

Confidential

Role: Business System Analyst

• As a Business Analyst, I was involved in multiple projects, primarily focused on ICD-9 to ICD-10 Mapping and Modeling Implementation process, claims processing Medical/Dental , provider and Reimbursement segment. I provided support through the entire lifecycle for multiple projects involving web service and user interface development, covering Provider, Claims and Reimbursement Processing domains. Also the project aimed to extend and expand the Physical Health Managed Care to all counties in the State of Nebraska. As a part of this project, Coventry Cares of Nebraska and Arbor Health Plan were brought in along with the already existing Plan and Managed Care services were provided to all the counties.
• I was also involved in a project for creating Investigative Services Information System ISIS . ISIS is a web based Case Tracking System which assists DHHS Office of Investigative Services in suspected fraud investigations for various programs, like Food Stamp EBT and non EBT cases, TANF, Child Care, Child Care Provider, EBT Vendor and also for internal investigations.

Roles and Responsibilities

• Acted as a liaison between Business area Subject Matter Experts SMEs development team throughout all phases of SDLC starting from Inception to Transition phase of Rational Unified Process RUP methodology
• Participated on meetings related to HIX impact on systems and the subsidies.
• Identified AS-IS process flow of ICD-9-CM and ICD-10-PCS compliance requirements using the gap analysis for the existing United HealthCare community Plan.
• Updated data processes, data reporting, data collection tools and other processes such as problem lists, writing orders, referrals according to ICD-10 code set.
• Ensured that ICD-9-CM procedure codes used for services and CPT codes were not outdated
• Contributed in ICD-10 Awareness Training Management Plan, created evaluation tool, and survey questions
• Reviewed state documents policies, manuals, business processes, systems documents, banners, bulletins from various divisions. Analyzed and performed quality assurance to determine areas impacted by ICD-9 related data
• Generated numerous Business Requirement Documents Functional requirements specification documents, Use cases, system flow and work flow diagrams.
• Worked with the Managed Care Subject Matter Expert SME and Users to ensure that all the requirements for system change are covered.
• Extracted and refined user requirements by conducting JAD sessions, facilitating meetings interview with Business Units and Technical Supports Development team, identifying the business flows and process flows, conducting detailed and comprehensive business, functional system analysis to determine High Level and Low Level artifacts deliverables.
• Developed business and detailed functional requirements related to changes to be made to the claim entry screens, including Practitioner, Crossover Practitioner, Dental and Hospital Claim Entry Screens.
• Involved in remediation of the legacy MMIS to meet the minimal functionality necessary to electronically send, receive and process the HIPAA compliant standard transactions, and fully implement all components of NPI Compliance.
• Incorporated and updated all MMIS screens for NPI Implementation within the MPS1 subpart used for paying claims
• Created new screen layouts and identified locations for new fields being added and existing fields which are being moved.
• Developed business and functional requirements for the National Provider Identifier NPI Crosswalk and Crossover Claims Crosswalk solution.
• Developed Test Plans and Test Execution Procedure Document based on the Business Functional Requirement Document and numerous Test Cases and Test Scenarios to cover overall aspect of quality assurance.
• Successfully tested all the test conditions, documented the defects and discussed with technical analysts the discrepancies between expected and actual results for the test conditions.
• Conducted knowledge transfer sessions which were used to make the users and other teams aware of all the changes being made in the system as part of various projects.
• Assisted End User in performing User Acceptance testing and performed testing of the end result files created by the development team to verifying whether all the User Requirements were catered to by the development effort.
• Worked with Team Leads, Technical staff and key users to identify track and manage project issues as they arise.
• Developed workflows that demonstrate current and proposed business requirements.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: MS Office, SQL Server, MS Project, MS Visio, Unix, J2ee, Java, XML, Windows XP

Confidential

Role: Business System Analyst

The object of the project was to make Molina Healthcare compliant, per HHS mandate, with the new HIPAA 5010 standards which will require modification to key HIPAA EDI transactions that support the following areas: Enrollment, Premium Payment, Eligibility Inquiry/Response, Referrals Claims Submission, Claims Status Inquiry/Response, and Claims Remittance. Other objective is to make Molina Healthcare ICD-10 compliant in order to accept ICD-10 structure.

Roles Responsibilities:

• Reviewed, analyzed created BRD's identified Functional Requirements Non Functional Requirements using Rational Requisite Pro.
• Conducted interview brainstorming sessions, JAD sessions, presentation sessions to capture clear, concise feasible requirements.
• Conducted GAP analysis identified loop, segment, field additions/deletions, error conditions changes between As-Is process To-Be process.
• Assisted in highlighting key aspects required for vendor solutions HIPAA 4010-5010 translators testing tools created vendor statement of work document.
• Identified conducted mapping process for output from 5010 to proprietary UB92 NSF formats for legacy payer systems.
• Captured key payer systems HIPAA repository data flow issues risks.
• Conducted Claim Adjudication check for payer edits rules , analyzed and identified any errors to generate 834.
• Conducted Gap Analysis identified specific ICD 10 requirements participated in development sessions capturing ERD diagrams, Workflows Communication diagrams.
• Created Project Plan using MS Project identifying key resource constraints, deadlines dependencies. Documented created weekly project status reports.
• Created Current Process Flow as-is process Future Process Flow to-be process using MS Visio.
• Created Use Cases, Activity Diagrams, System Context Diagrams entailing grandfathering process, preexisting condition exclusions, dependent coverage age increase other required provisions.
• Made improvements and suggested innovative designs for the existing UI design of Molina Healthcare
• Created Test Case Prioritization as critical/high/medium/low obtained TL approvals.
• Conducted positive negative testing produced test status reports for KIOT meetings.
• Used Ultra Edit Professional to format ANSI X12 EDI 837I,P,D files , identified changed duplicates, changed loops, elements segments, wrapped unwrapped files.
• Used Ultra Compare Professional to do 3-way comparison among ANSI X12 EDI 837I,P,D files
• Logged defects using Rational Clear Quest produced defect status reports to ensure quality standards

Environment: Mainframes, DB2, Rational Requisite Pro, Rational Clear Quest, Rational Test Manager, Oracle 10g, UML, MS Office, IBM Lotus Notes, Windows XP.

Confidential

Position: Business Analyst

• Confidential operates as a managed health care company in the United States. Its health plans and government contracts subsidiaries provide health benefits to approximately 6.0 million individuals across the country through group, individual, Medicare, Medicaid and TRICARE, and Veterans Affairs programs. In addition, it owns health and life insurance companies, which are licensed to sell preferred provider organization, point-of-service, and indemnity products, as well as auxiliary non-health products, such as life and accidental death and dismemberment, dental, vision, behavioral health, and disability insurance.
• The project concentrated on developing Claims record system that would validate patient demographics and could also verify insurance claims eligibility in real time. The salient features of this project were Medicare/ Medicaid Eligibility and Billing Verification, Self-Pay/Commercial Eligibility and Billing Validation, Real Time Processing, Billing Address Verification with Address History and Insurance Eligibility Verification.

Responsibilities:

• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Built and customized SoDA for Word templates and extract information from information sources such as RequisitePro and Rose, and created a highly automated system for handling approvals, exceptions and priorities.
• Used the Agile methodology to build the different phases of Software development life cycle.
• Gathered Business Requirements. Interacted with the Users, Designers and Developers, Project Manager to get a better understanding of the Business Processes.
• Developed gap analysis document, logical and physical design and remediation plan for State.
• Responsible for mapping documents, creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Worked with business owners, content staff, IT and other stakeholders in creating a content management solution for managing the information in the supplier portal using WebSphere Application Server.
• Used the Rational Unified Process RUP to build the different phases of Software development life cycle
• Created Project management plans for managing on time delivery using MS Project along with writing test cases, unit and systems integration test plans in Win Runner and used Load Runner to check if application works fine with load.
• Followed the UML based methods using Rational rose to create use cases, activity diagram, sequence diagram, collaboration diagram that include functional and non-functional specifications to hand off to development teams.
• Interaction with the business user and the IT team for understanding the requirements.

Environment: OO Modeling, Web Sphere, Rational RequisitePro, Rational Rose, Rational SoDA, RUP, UML, Win Runner, Load Runner, MS-Project, MS Visio, MS Office, Windows XP.

Confidential

Role: Business Analyst

The scope of this project included offering OSB's Optional Supplemental Benefits to Individual MA/MAPD plans with higher Premiums, and also to plans that no longer offer any Dental/Vision benefits, or any other benefits such as, alternate medicine, international coverage etc. The advantage of offering these OSB plans is giving seniors the choice of selecting optional packages along with their base plan, which in turn allows them to customize their health care coverage depending on their individual needs.

Roles and Responsibilities:

• Analyzed, documented, and managed all project requirements and changes to requirements throughout the software development lifecycle.
• Created the architecture flow, rating modules structure and the database structure of the Optional Supplemental Benefits OSB which was used by the downstream systems
• Responsible for the team status meetings, reporting and updating reports in the eRoom Documentum
• Facilitated the group discussions with the architects on the ways of structuring the benefits, benefit codes, rate type codes, package keys and OSB relationships
• Developed all the required documents SRS, Design Document, Use cases, Data Flow diagram, Test Plan, Test Cases, UAT testing template etc. using MS Visio and MS Office
• Developed the design specification, testing information use cases , installation instructions, and user documentation which provided end-to-end IT Service Management based on ITIL
• Responsible for scheduling meetings, one on one sessions and facilitating System testing and UAT with all systems and business partners
• Prioritized defects, Service desk tickets and enhancement requests from business partners
• Created and monitored various departmental metrics and new project impact reports
• Designed and implemented cost and staffing models
• Documented the workflow structure of creating the questions for the benefits, approving the benefits and rates from CMS, enrolling customers and groups to the benefits, billing cycles, claims and information printed on the ID cards
• Responsible for the overview of the production support maintenance, support and improvement
• Responsible for managing, updating and reporting the project status on the weekly project management meeting
• Facilitated the User Acceptance Testing process, developing rollout plans and procedures
• Created various business process quick reference guides and process flow stop help business partners understand the CMS guidelines, their work and responsibilities
• Responsible for implementation and coordination of the automated testing tool Certify for the regression testing of the renewal cycles, batch jobs and various screens in the mainframe system

Environment: MS Office, SQL Server, MS Project, MS Visio, Unix, J2ee, Java, XML, Mainframes, Windows XP.