PROFESSIONAL SUMMARY

Astute, Business Analyst with 6 yrs of consulting experience including Healthcare and Insurance. Possess strong business process modeling skills, and performs interviews and meetings to conceptualize business processes, gather requirements, and to design artifacts including UML Use Cases and Activity diagrams. Demonstrated expertise with Medicare and Medicaid, including Claims, Adjudication and Billing. Skilled at activity diagramming, and developing use cases Models and documents. Skilled at facilitating JAD sessions, interviewing, document review, and brainstorming, in order to document artifacts such as BRDs, FRS, Use Cases, Activity Diagrams, Test Cases, and Test Plans. Extensive experience in Healthcare industry including HIPAA regulations, and EDI standards X12 and HL7 . Experience developing process maps, and AS-IS and TO-BE process conceptualization and improvements. Have strong facilitation, collaboration, and communication skills. A hard-working and results-oriented analyst who consistently goes the extra mile, and is known for teamwork, and character.

TECHNICAL SKILLS

PROFESSIONAL EXPERTISE

• Expert at assessing business requirements and defining traceable, understandable application requirements
• Experience with Medicare and Medicaid Claims processing, Membership, and Eligibility Verification
• Thorough knowledge of Eligibility and membership Affairs for Medicare and Medicaid also knowledge of HIPAA, X12, and HL7 standards, and Medicaid provider best practices
• Experienced with System Development Methodologies SDLC , Prototyping, ER Modeling, Functional Hierarchy Diagrams, Data Flow Diagrams, RDBMS, Object Oriented Programming Approach, Design Patterns, UML, Data Warehouse ETL/OLTP/OLAP , Unix Shell Scripts, Service Oriented Architecture SOA , SharePoint BizTalk Messaging.
• Strong knowledge and experience in healthcare industry working knowledge on HIPPA and Medicare Management Information System MMIS .
• 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.
• Experience in writing Business Requirements Document BRD , Functional Requirements Document FRD , Request for Proposals RFP , Statement of Work SOW
• Extensively worked on MS Access, MS Excel, MS Visio, MS PowerPoint, MS Project, and Oracle/ SQL.
• Extensive experience in requirements gathering, feasibility analysis and successive documentation in project related artifacts like the User, Functional and System Requirements Specification documents
• Experienced with Medicare and Healthcare Insurance as well as Medical Standards HIPAA and HL7
• Extensive experience in Unified Modeling Language UML modeling, including Use Cases, Activity diagramming with swim lanes, and Context diagrams using tools such as MS Visio
• Extensive experience in enterprise data modeling and analytics SSRS, SSAS, SSIS, ETL, MDM, Entity Data Models and data warehousing incorporating transaction oriented business/service level data processes and metadata collection techniques to enhance informatics strategies.
• In depth understand analyzing various 834/837 claims of Inbound Outbound process of X12 through Xengine until Submission file to State in ETL Process for Various LOB's.
• Used Spec Builder to check SNIP levels of X12 files for various EDI transactions
• Built Queries to test various Pharmacy, Medical Regulatory Reports for various Line of Business
• Worked on Data Analysis Reporting for Data Conversion/Migration project.
• In depth knowledge Rational Unified Process RUP methodology, Use Cases, Software Development Life Cycle SDLC processes, Object Oriented Analysis and Design OOA/D .
• Providing solutions and enhancements for product, reporting, and application functions
• Comprehensive background in all areas of Medicaid and Medicare billing and claims processing
• Experience testing implemented systems and system changes including liaising with QA teams to develop test cases, test plans, test scenarios, and generating test data and conducting manual testing regression, end-to-end, functional
• Creating artifacts such as URS, FRS, Traceability Matrix, project plan, BRD, test plans, and test cases
• Experience running scripts to check web user interface and Portals for Broken Links, Frame Properties, Table Properties, URL links, Images, Text and prepared Test Metrics to test execution status and results
• Proficient in creating User Acceptance Test UAT Plan and implementing and coordinating UAT
• Developing AS-IS and TO-BE systems, and translating business needs into technical changes / developments
• Experience and understanding of Healthcare and Health Insurance business models and operations including Enrollment, Membership Management, Claims Processing, and Client Management
• Has demonstrated excellent interpersonal as well as written and verbal communication skills

PROFESSIONAL EXPERIENCE

Confidential

Business Analyst

Description: EngagePoint is helping government agencies and commercial insurers meet the complex challenges of healthcare reform and system modernization. As a fast-growing healthcare software and IT services firm, EngagePoint's unique expertise in healthcare technology is enabled to create custom solutions that empower customers to bend the cost-of care curve while increasing efficiency and collaboration. The project is to work on the eligibility and enrollment framework wherein ultimate goal was to migrate data from the Legacy system to CURAM in order to facilitate enrollment of those deemed eligible into the Medicaid expansion.

Responsibilities:

• Facilitated Joint Application Development JAD Sessions for communicating and managing expectations and to discuss the different ways and means for migrating data.
• Gather requirements from the stakeholders and facilitated meeting for a final sign off as well as developing and maintaining business rules.
• Documented requirements along with a detail data analysis of the systems involved and defined data mapping rules and created source data for the ETL.
• Worked on healthcare standards such as HIPPA 4010, 5010, ICD-9 and SOAP.
• Document the business processed surrounding Medicaid claims, benefit plans, claims payment cycle, waiver programs, and references.
• Involved in analyzing and gathering requirements for various EDI 834 transactions also SAS reports which includes Analyzing address type of the members, calculate the age of the members, CSV zip code information for the SMI members, Acuity, HI BH Druglist, Access To Medication etc
• Worked as the primary liaison between the business user and the developers throughout the project cycle.
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the change in the proposed system.
• Worked with CURAM System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 834 and proprietary format files and Reports development.
• Preparing the guidelines of migration to organize the business rules for conversion from scratch.
• Used Toad for Creating and executing SQL Queries for Data Analysis and extensively involved in Database testing.
• Wrote test cases and test scripts for the User Acceptance testing UAT and supported unit, integration and regression testing.
• Setup Procedures to Extract, Transform and Load ETL data from Operational and Legacy Systems to the Data Warehouse by Using Informatica.
• Authored data flow diagrams, sequence diagrams, and business process models that describe how the data is anticipated to flow from one system to another.
• Experience in writing SQL queries to validate data while performing research/analysis and data modeling.
• Created Interfaces and writing Data Mapping Documents, Data Transformation Rules and maintaining Data Dictionary, Data Migration and Interface Requirements Documents.
• Actively participated in status report meetings and interacted with developers to discuss the technical issues.
• Setup Procedures to Extract, Transform and Load ETL data from Operational and Legacy Systems to the Data Warehouse by Using Informatica.
• Responsible for defect tracking and bug reporting using JIRA interacted with developers and Business Analysts to discuss and resolve defects.
• Involved in daily defect review meetings to review the status of defect fixes and upcoming build releases.
• Verified and validated all the build or release related issues and resolve then through discussion with business analysts with the users approval.

Confidential

Business Analyst

Confidential offer innovative health insurance coverage and a full range of health and wellness plans for groups and individuals. Amerigroup offers health care services through three government programs that target different segments of the country's low-income population: Medicaid, the Children's Health Insurance Program CHIP and Medicare. In this project I have been working on HIPAA 4010 to 5010 system transition where we have been endeavoring to ensure that we attain minimal functionality to process new 5010 version EDI X-12 transactions. I have been involved from initial impact analysis to testing and validation efforts and have delivered some critical artifacts including BRD, TRD, mapping document and companion guide. The system streamlined patient registration, patient scheduling, and medical insurance checking, claims processing, and reporting. The purpose of this project involves population of the Enterprise Data Warehouse EDW which is used in critical reporting and analysis. The data is pulled together from multiple, disparate systems.

Responsibilities:

• Utilized SDLC Methodology to configure and develop process, standards and procedures
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business workflows task analysis and determine whether any current or proposed systems are impacted by the new development efforts.
• In depth analyzing testing for 834/835 Inbound Outbound process of X12 through X-Engine until Submission file to State in ETL Process for Various LOB's.
• Coordinated with various IT teams related to various backends WGS, Facets, Nasco etc for Test Data Setup in SIT UAT environments
• Designed Test Plans, Scripts after analyzing various scenarios/requirements performed defect tracking using Test Director Clear Quest
• Projects included designing retail architecture for Do Not Solicit, Customer Proprietary Network Information, U-Verse and DSL product sales and Order Life Cycle Reporting applications. Adhered to a Service-Oriented Architecture framework and utilize System Development Life Cycle and IT Unified Process techniques for all ongoing projects.
• Facilitated problem solving, client interface interaction design, analysis of data flow/data model, and technical leadership with business intelligence teams.
• Performed User Acceptance testing End to End testing in interaction with Offshore QA/dev teams for various system releases pushed them to production
• Provided Production support, documented System Release/deployment issues SOX documentation for Business Signoff.
• All work performed in a SOA Service Oriented Architecture and using an Agile development methodology.
• Design/implement multiple enterprise business intelligence solutions to create
• Created Data Stage jobs to extract, transform and load data into data warehouses from various sources like relational databases, application systems, temp tables, flat files etc.
• Analyzed various 834 Claims, Membership, Billing, Benefit and plan
• Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed 834,835
• Responsible for writing the Test Cases and Test Scenarios based on the Functional Specification and technical Specification and documented in Mercury Quality Center.
• Author release management plans, release notes and code migration documents.
• Developed SQL queries, functions, stored procedures and triggers to perform the backend testing of the data
• Always maintained excellent problem-solving and communication skills and effectively listened, negotiated, debated, discussed, brainstormed, communicated, and collaborated with a variety of individuals and groups

Environment: Life70, DB2, QSAM, VSAM, TeamWorks, EZTRIEVE, COBOL, Assembler, J2EE, MS SQL Server 2005, MS Office, MS Visio, Certify, MQC, VB.Net, Java

Confidential

Business Analyst

MEHIS: The MEHIS Medicaid Eligibility Health Information Services Program will implement changes and enhancements to interfaces as needed to respond to changes to external systems. The MEHIS Program must incorporate Service Oriented Architecture SOA and Health Level Seven HL7 standards in the development of data exchange interfaces for both real-time data messaging protocols e.g., Health Insurance Portability and Accountability Act HIPAA Eligibility Transaction System HETS 270/271 transactions and for batch file processing. HHSC will work with TMHP and the MEHIS Vendor to identify and consider incorporation of other emerging standards i.e. XDS-B, MITA as available and applicable.

Responsibilities

• Evaluated business process requirements to ensure proper system configuration i.e. identifying key decisions, process changes, pain points, interface issues, training considerations, etc.
• Managing software projects development and delivering custom made solutions based on Service Oriented Architecture SOA.
• Served as a liaison between the internal and external business community Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management and the project team
• Understood the healthcare plans offered, including Medicaid Managed Plans such as Children and Adolescent Care, Women's Preventive Care, Maternal Care, Asthma Care, Diabetes Care, Cardiovascular Care, and Mental Health
• Performed Functionality testing, Integration testing, System and UAT. Documented and logged the results and defects.
• Gathered AS-IS and TO-BE information about Affinity Health Plan's work processes and information flows Claims process, Membership, Enrollment , and conceptualized using swim lane activity diagrams
• Created and reviewed User Requirements Document, Use Cases, and Functional Requirements Document
• Gathered and prioritized requirements, developed business scenarios to check how the system would work with the roles and processes of the departments, and developed acceptance criteria
• Used the DataStage Designer to develop processes for extracting, cleansinfg, transforms, integrating and loading data into data warehouse database.
• Facilitated review of Enrollment, Claims, Commissions, and membership portlets' designs with architects and developers to ensure that the goals of the portal requirements were satisfied
• Utilized Microsoft SQL 2005 and associated business intelligence tools SSIS, SSAS, SSRS to provide focused transaction and task monitoring and error handling on an enterprise level.
• Produced UML Activity diagrams with defined swim lanes using MS Visio as part of claims process analysis
• Brought valuable knowledge and solutions to business groups to enhance competitive edge with Facets Extended Enterprise TM administrative system implementation
• Contribute in the build and design of an automated documentation system that met business process needs by providing comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management
• Analyzed Tested HIPAA Gateway Application Interface for all inbound and outbound messages Healthcare Eligibility 270 and 271, Healthcare Claim Status request 276 and 277, Healthcare Claim 834
• Participated in all phases of the Facets Extended Enterprise TM administrative system implementation including the planning, designing/building/validation DBV , testing, and Go-live support phases
• Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments, facilitating/presenting DBV sessions, and assist with integration testing
• Worked on modules related to Providers, Contract Claims and worked with Claims, Provider attributes, enabling EOB Remit rules associated with Provider configuration process in Facets.
• Conducted User Acceptance Testing and user training pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity mainly occur with EOPs, capitation rosters, PCP membership rosters, provider directory listings and some system generated letters

Environment: Facets4.7, Facets Extended Enterprise TM , Oracle, MS Word, Windows XP, S SQL, VB.NET, HTML

Confidential

Business Systems Analyst

The Palo Alto Medical Foundation PAMF is a non-profit healthcare organization that is a pioneer in both multi-specialty group practice of medicine and outpatient medicine. PAMF needed to implement an Electronic Medical Records EMR solution, which would help the physicians and other medical support staff provide better care to their patients and give the patients the option of accessing their medical records online from the comfort of their home. The project involved creating an Information Management System using software solution provided by Epic Systems. This system allowed the users to make appointments, ask questions, initiate claims, and obtain medical records online. This system also allowed the Doctors, Nurses, and the Receptionists to manage patient membership data

Responsibilities

• Gathered User and Business Requirements through interviews, surveys, prototyping and observing Stored and modified requirements.
• Liaised between technical and business teams for obtaining status/updates as well as sharing best practices.
• Created Need Analysis Documents of the requirements gathered through JAD and JRP individual elicitation sessions using MS Word.
• Created User Requirement Specifications URS , Business Requirement Document BRD and Functional Requirement Specifications FRS documents.
• Created Use cases, Use Case Diagrams, Activity Diagrams, Business Flow Diagrams and Business flow diagram using Rational Rose and Rational Requisite Pro.
• Involved in analysis of the technical specifications of the current system and the infrastructure needs performed Gap analysis.
• Created complex stored procedures using SQL with multiple table joins and comprehended and isolated areas problems.
• Made Screen Mockups/Definitions and Dependencies using Excel.
• Extensively used SharePoint to document project processes and procedures, communicate requirement and version control them.
• Collaborated with Quality Assurance Analyst in Rational Clear Quest to track defects and used Rational Clear Case to maintain consistency in the builds.
• Experienced setting up test scenarios and executing on these scenarios and worked closely with testing team to make sure all the changes made to requirements documents are implemented in there Test Cases
• Maintained various versions of the documents generated during the project using Rational Clear Case
• Used Agile development methods to promote development iterations, team work, collaboration and process adaptability and strong experience with Scrum
• Created User Stories to capture all requirements.
• Set up definitions and process for test phases including Product test, Integration test, System test and User Acceptance Test UAT .
• Conducted GUI testing, Functional Testing, Smoke Testing, Integration Testing, Performance and User Acceptance Testing on the application.
• Extensively worked on Mercury Test Director for bug reporting/tracking.
• Worked with SQL extensively to test database integrity.
• Involved in maintaining the Requirements Traceability Matrix RTM across the deliverables for a project
• Conducted Training Sessions to familiarize users with system.

Environment: Agile/Scrum, Rational Rose, Rational Requisite Pro, UNIX, MS Visio, MS Project, MS SharePoint, HTML, Windows, Oracle, SQL, people soft, IBM Web sphere, Business Intelligence.

Confidential

Business Analyst

Confidential is an independent, non-profit managed care plan that serves the needs of over 210,000 underserved residents of the New York Metropolitan Area New York City, Long Island, Westchester, Rockland and Orange Counties. Affinity provides healthcare coverage through its Child Health Plus, Family Health Plus and Medicaid programs. Affinity Health Plan implemented Facets Extended Enterprise TM administrative system, a new core system, with updated technology to allow for more efficient claims processing, membership enrollment and provider data maintenance. Facets was highly efficient, automated, customizable, and flexible, to help affinity tackle new business opportunities and compete successfully in a dynamic healthcare industry. Moreover, TriZetto provided ongoing support and training.

Responsibilities

• Assisted in the Project manager in creating and updating the Vision Documents, Business case, and the Project Plan to define Objective, Scope and Risks. Also assisted in creating RUP iteration plans and phase plans
• Elicited requirements, and managed Change Configuration to maintain an orderly procedure for managing requirement changes after sign off
• Elicited functional specifications, conducted feasibility analysis, and performed impact analysis
• Elicited Business Rules and other Non-functional specifications for the new system by interviewing the Subject Matter Experts Doctors Nurses to further understand the business models
• Authored functional specifications for different HL7 system interfaces: ADT registration , SIU scheduling , OMG rad order entry , and ORP/RDS Rx processing
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Documented and reported feedback made by users. Documented out of scope but relevant requirements to aid in new Initiatives or Enhancement projects future upgrades
• Created Request For Proposal to identify possible vendors and obtained cost and functionality information
• Created UML Activity Diagrams to depict business processes AS-IS and TO-BE and analyzed them for their efficiency and productivity
• Tracked UAT issues/bugs and prepared reports.
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
• Created Use Case Model using Rational Rose for developers and other stakeholders to understand the business process, depict roles, and procedures
• Facilitated requirement-eliciting sessions JAD sessions with Subject Matter Experts and other Key Users and documented the requirements in an easy to understand format by both the business and technical personnel
• Constructed Use Cases and Wireframes and translated them into a Functional Requirement Specifications document
• Performed manual testing, including validation/smoke testing of HL7 interface messages on each new build before delivering to quality assurance team
• Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data
• Created Online User Guide comprising different scenarios, screenshots, and troubleshooting procedures

Environment: MS Project, MS Excel, MS Word, Rational Rose, MS PowerPoint, UAT,Oracle 9i, Citrix server , Epic

Confidential

Business Analyst

Confidential is one of the nation's largest consumer health organizations, offering individuals, employers and Medicare beneficiaries a variety of consumer-driven health care and insurance products. Specialty operations include behavioral health, dental and vision, life insurance, and complete pharmacy and medical management through its wholly owned subsidiary, Prescription Solutions. PacifiCare Physicians and Associates were swamped under the huge volume of paperwork associated with submitting claims for payment. Due to coding mistakes and data entry errors, PacifiCare saw their claim resubmission rate soar to 20 percent which delayed payments every month. The solution was to implement ClaimsEditor Professional, an application that would that would reduce costs from claim denials, re-submissions and write-offs, speed reimbursement and improve regulatory compliance

Responsibilities

• Worked in accordance to the activities/roles laid down in each phase of software development life cycle created using Rational Unified Process
• Created specifications for EDI HL7 A28, A31, ADT and X12 834/837 transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers
• Organized meetings to elicit expert knowledge of the TO-BE business process in an effort to generate requirements
• Analyzed business requirements and created Use Cases, activity diagrams using MS Visio
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests
• Updated requirements document, Use Cases, and FRS according to Change Control Committee's approval of CR and the Traceability of the documents
• Performed GAP Analysis by comparing the existing system to the future system to create AS-IS and TO-BE flow charts and generating risk assessment
• Drafted a Traceability Matrix in Excel and imported it into Rational RequisitePro
• Worked as a liaison between the developers and the QA team in creating the Test Plan and Test Cases using Rational Test Manager. Generated test data, and assisted QA team with manual testing whenever possible
• Maintained and Reviewed Change Requests and documented all analysis
• Conducted User Acceptance Tests to ensure that all mutually agreed upon user requirements had been met and to gather additional requirements for enhancements to the application for future release

Environment: J2EE, XML, HTML,UAT,WebLogic, Oracle9i, MS Word, MS Outlook, MS PowerPoint, MS Visio, Rational RequisitePro