Summary:

• Qualified professional with over eight years of extensive experience in the field of Business /Data Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare and Healthcare Insurance Industry.
• Extensive hands-on and HealthCare management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support the Medicaid Management Information System MMIS as well as day-to-day business operations.
• Extensive experience with Medicare/Medicaid processing as well as the Claims/Billing.
• Highly motivated team player with excellent communication, presentation and interpersonal skills, always willing to work in challenging and cross-platform environment.
• Experienced as a Business Systems Analyst in using the iterative software development life cycle principles of Rational Unified Process to manage, develop and test distributed client/server, internet and intranet applications on heterogeneous environments.
• Extensive knowledge of Salesforce.com implementation cycle in Sales, Marketing, Service and support modules.
• Experience in SalesForce Testing and Administration spanning all facets of package software and SaaS application implementation
• Strong understanding of medical coding and transition from ICD 9 ICD 10
• Highly proficient in working with users to gather requirements, analyze them and subsequently use the Rational project and design tools to model the requirements.
• In-depth knowledge of creating use cases, functional design specifications, activity diagrams, logical, component and deployment views to extract business process flow.
• Experience with HIPAA/EDI UB-82, UB-92 and HCFA 1500 claims, and HEDI information working on ICD9/ICD10 initiative.
• Configured security and organizational hierarchy for sales for salesforce implementation.
• Involved in Design and development of Workflows rules, triggers, validation rules and other customizations with Salesforce.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Experience with SOX, Regulatory Compliance and Controls.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications.
• Familiar with HIPAA EDI transactions such as 835, 837 P, D, I 276, 277, 278 etc
• Worked on FACET modules such as pricing, payer, eligibility under claims processing system.
• Gathered and documented Non-functional requirements.
• Knowledge of healthcare standard Health Level Seven HL7 .
• Conducting requirement gathering sessions, feasibility studies and Impact Analysis and organizing the software requirements in a structured way using Rational RequisitePro to track development.
• Interacting regularly with the development team, creative services, database designer, system administrator and the higher management to meet the deadlines of Project milestones.
• Worked in close co-ordination with the testing team in developing test plan and test cases from functional and business requirements.
• Served as a point of contact for CMS and trading partners to do the testing for various types of claims and real time transactions like 270/271/276/277 for Medicare and Medicaid programs in FACETS.
• Performed UAT and exposure to User Certification Testing UCT and Operational Readiness Testing ORT
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Used Rational ClearQuest for tracking and prioritizing defects and for enhancements after base lining the requirements.

TECHNICAL SKILLS:

Business Tools: Rational Suite Requisite Pro, Rose, Clear Quest, Clear Case , MS Visio, MS Project, MS Access, MS Office Suite, Visual Paradigm, Doors Erwin Data Modeller 4x,

Business Skills: Business Definition Requirements, Business Process Analysis, Gap Analysis, Use Case Modelling Analysis, Business Environment and Market Research Analysis.

Methodologies: RUP, OOAD, UML Business/Data Modeling

Testing Tools: Win Runner, Load Runner, Test Director, Quick Test Pro, PR Tracker

Operating Systems: Windows XP/95/98/NT/2000, Mac OS X, DOS, UNIX, Linux

Databases: Oracle 8i/9i SQL Server 7.0 2000 Access 2000, MS SQL Server, DB2, Facets

Languages: UML, C, C , HTML, Java, SQL, PL/SQL, ASP.NET

PROFESSIONAL EXPERIENCE:

Confidential

Business Data Analyst

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams.
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Facilitated preliminary sessions with the client SMEs for the upcoming 5010 transaction sets on Claims and Payment. Identified needed modifications for upcoming ICD9/ICD10 directives from the then available documents from World Health Organization, and CMS.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Developed a web-to-lead functionality to vertrue.com site which directs leads to Salesforce CRM.
• Created various Reports and Report folders to assist managers to better utilize Salesforce as a sales tool and configured various Reports for different user profiles based on the needs of the organization.
• Familiar with Syntellect Phonelink CTI salesforce application which is used to provide agents with click-to-dial and screen pop capabilities.
• Customized page layouts for Salesforce standard and custom objects.
• Used SalesForce for managing customer relationship and opportunity tracking.
• eployed Salesforce.com at enterprise, global implementation scale.
• Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
• Technical Specification Creation for EDI. Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Developed S-Controls to manage sales plan call sheets within salesforce, capturing prep data and call activity.
• Customized Salesforce out of the box functionality including assignment rules, escalation rules, validation rules, custom fields, page layouts, workflows, approvals and actions.
• 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.
• Worked on various salesforce.com standard objects like campaigns, leads, accounts, contacts, opportunity, forecast, cases, reports and dashboards.
• Good experience in Salesforce.com Configuration of roles, profiles, user accounts, implemented role hierarchies, sharing rules and record level permissions to provide shared access among different users.
• Configured standard salesforce objects and custom objects as per business needs implementing validation rules and formula fields.
• Gathered requirements for all automation workflows as per business requirements and translated in to salesforce business terms.
• Worked with BA and UAT tasks involving FACETS application and claims processing.
• Experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C D, FACETS 4.5/4.7 system, Claims Processing, Insurance Pricing and Claim Adjudication. Strong Experience in FEP Federal Employment Program and CDA Clinical Development Analytics . Healthcare Domain Knowledge with SQL knowledge in Oracle environment and 5010, ICD-10 experience.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Worked on customizing the claim module of FACETS for repricing Nursing home claims
• Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System MMIS .
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Designed the online screens and reports for the Medicaid Online Electronic Claims Submission System.
• Responsible for business system analysis of customizing the BPS Risk Management product with involvement through the whole SDLC.
• Consultant in Healthcare Strategy for ICD-10 Assessments and Implementation Strategy Engaged as Lead for Strategic Planning
• Incorporated Rational Unified Process RUP to create Business Requirement Document Specifications using MS Visio and MS Word.
• Ensured EDI 5010 837P/I transaction files with ICD-10 codes must be loaded to the applicable claims system
• Establish documentation for agile methodology for implementation with a very water-fall-centric development team.
• Extensive use of MS Office tools like MS Access, MS Word, MS Excel, MS PowerPoint MS Project for data migration in to the CI System Knowledge Data Base in Microsoft SharePoint Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Involved in all phases of software development life cycle in RUP framework.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• 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
• Ensured current EDI 278 business validation rules applicable to ICD-9 codes will also apply for ICD-10 codes
• Developed detailed Developer specification to reflect technical details of the business requirements
• Performed data analysis by using SQL queries using the DB Artisan tool
• 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.
• Analysed processes in medical coding and transition from ICD 9 ICD 10.
• Worked with HL7, EDI ANSI 4010 and 5010 Standards Knowledge of ICD 10
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team.

Environment: MS Office, MS Visio, Rational Requisite Pro, Rational Rose, Facets, Rational Clear Case, Rational Clear Quest, Quality Centre, RUP Methodology, EDI.

Confidential

Business Analyst

Responsibilities:

• Performed Requirement Analysis by gathering both functional and non functional requirements based on interactions with the process owners stake holders and document analysis, represented them in Requirements Traceability Matrix RTM .
• Validated the following: 837 Health Care Claims or Encounters , 835 Health Care Claims payment/ Remittance , 270/271 Eligibility request/Response , 834 Enrollment/Dis-enrollment to a health plan
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Performed System testing of the Claims processing systems Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment, et al .
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System MMIS .
• Worked on ICD-9 to ICD-10 conversionin FACETS.
• Data mapping on Enrollment Module EDI 834 of FACETS.
• Worked on FACET claim processing system.
• Worked with various Salesforce.com objects like Accounts, Contacts, Leads, Opportunities, Reports and Dashboards.
• Implemented S-Controls to manage sales plan call sheets within Salesforce, capturing data and call activity.
• Gathered requirements for all automation workflows as per business requirements and translated in to salesforce business terms.
• Experience in extensive database testing and Back End Testing using SQL queries with MySQL database Performed Manual Testing of the Application to determine ease of usability.
• Participated in UAT testing with end clients.
• Ensured that ICD-9-CM procedure codes used for inpatient services and CPT codes for outpatient and physician services were not outdated
• Analyzed the functionality and came up with test scenarios for split-billing process on FACETS
• Participated in Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10.
• Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM Health Trans and Claims Accumulation and Adjudication is done through Diamond.
• Worked on receiving Encounter files from their PBM Pharmacy Benefit Manager , verifying the data content by transactional analysis.
• Facilitate System Integration Testing on FACETS systemtoverify HIPAA compliance from 4010 to 5010.
• Performing Impact analysis for readiness of ICD-10 conversion.
• Performed Analysis of ICD 9 Procedure and Diagnosis Codes in accordance with ICD 10 CM and ICD 10 PCS Conversion Compliances
• esting of different types of ICD 9 as per requirements
• Worked on As-Is To-Be analysis of ICD9 to ICD 10 conversion for the new qualifiers used in the 837 claims for the diagnosis and procedure/HCPCS codes.
• Used XML for building and parsing of Application Configuration file.
• Responsible for gathering requirements from users in operations group and performing data mapping for the application, confirm and vacillating the requirement at time of BA testing.
• Excellent knowledge of Enterprise Portfolio Management systems like Clarity, PlanView and MS Project Server.
• Interacted with department heads to finalize business requirements, functional requirements and technical requirements and also created Business process model.
• Captured all HIPAA-related EDI data in the repository using FACETS.
• Involved in mentoring specific projects in application of the new SDLC based on the Agile Unified Process, especially from the project management, requirements and architecture perspectives.
• Prepared and analyzed AS IS and TO BE in the existing architecture and performed Gap Analysis.
• Created workflow scenarios, designed new process flows and documented the Business Process and various Business Scenarios and activities of the Business from the conceptual to procedural level.
• Assisted in GAP Analysis identified and documented improving area to meet the end state requirements.
• Conducted Gap Analysis, and Gathered User Requirements by Interviews, user meeting, JAD session, and Requirement Elicitation Sessions.
• Accepted inbound transactions from multiple sources using FACETS
• Supported integrated EDI batch processing and real-time EDI using FACETS.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.

Confidential

Business /Data Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for writing Functional Requirement Specifications FRS and User Requirement Specification URS .
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Gathered requirements and created BRD for the Washington State Medicaid managed care incoming 834 enrollment file / data to the Amerigroup FACETS for Accumulator Synchronization using ABI Subsystem to load in Facets Accumulator.
• Analyzed Inbound and Outbound file layout in Facets delimited keyword format and successfully design and developed technical requirements.
• Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches membership, Billing, Provider, etc .
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Designed a claim processing system for the healthcare management client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms ICD-9 codes , and treatment CPT .
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. 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.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Involved in Service Oriented Architecture SOA of the claims processing system
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Performed extensive requirement analysis including Data analysis and Gap analysis.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Coordinating and Developing QA activities.
• Assigned tasks among development team, monitored and tracked progress of project following Agile methodology.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.

Environment: Requisite Pro, Rational Rose, Agile, HL7Interfaces, PL/SQL, HTML, facets, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.