SUMMARY:

• 7+ years of extensive experience in the field of Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Combined experience in Software Development Life Cycle and Business Analysis: experienced in gathering user requirements, documenting requirements, technical writing, business analysis, system analysis, testing, and implementation of projects.
• Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollmentand eligibility processes Experience with different modules within healthcare (Sales, Membership, billing, enrollment, claims, capitation, and providers).
• Expertise in Software Development Life Cycle (SDLC) and Project Management Life Cycle (PMLC), Data Analysis, Post Test Analysis, Object Oriented Design, SOA and Execution of Software Systems employing Industry proven software engineering best practices & support processes.
• Strong knowledge of managed care payer requirements and procedures.
• Experience in preparation of Deliverables, Business Requirement Documents (BRD), detailed Functional Specifications and Non-Functional Specifications, developing Use Cases and Test Cases
• Good understanding of MITA and MMIS functional business areas which include claims, providers services, providers enrollment, recipient services etc
• Hands-on experience with claims adjudication tools: MMIS and Facets
• Proficient in using Agile Scrum methodologies, performed roles of Scrum Master following sprint/standup sessions and used Excel extensively to write user stories, analyzed the Iteration Burn Down charts and reviewed defects.
• Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA(Patient Protection and Affordable Care Act), Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
• Extensive experience working in back end tester by writing SQL Queries and PL/SQL scripts on large data warehouse systems involving Terabytes worth of data.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Extensive experience in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from a Operational Data Store to a Enterprise Data Warehouse
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Highly skilled in creating, writing, and executing Test Cases, Test Scripts from Business User Requirement documents and Functional Design Documents.
• Experience in Creating Business Requirement Documents (BRD), Use Cases, Functional Requirement Documents (FRD) and Use Case Narrative.
• Strong business knowledge of Healthcare sector and very good knowledge about HIX and proven experience with ICD9-ICD10 conversion.
• Interacted and involved with Business users to gather requirements and support them with Business Intelligence solutions and products.
• Experience working on Healthcare Reform Projects such as Health Insurance Exchange (HIX), ICD 10 Remediation and HIPAA 5010 Implementation.
• Experienced working with x12 version 5010 transactions and ICD 10-CM and ICD 10-PCS Code set changes analysis, design and migration strategy.
• Solid understanding of Business Process definition, Risk Analysis and SDLC methodologies
• Experience with Business Intelligence, Data Analysis, Data Mapping, Data Privacy, Data Compliance, Documenting Business Requirements, Functional Requirements.
• Good working knowledge of Claims processing, HIPAA Regulations and 270, 837P, 837I, 837D EDI Transactions for health care industries.

TECHNICAL SKILLS:

Software/Hardware: RUP, UML, SDLC, Agile/Scrum, Waterfall, ETL, QA, MS Access, Amisys, SQL Server, MySQL, PL/SQL, Oracle, DBA,DB2. Windows 98/2000/XP, basic UNIX, HTML, basic DHTML, basic XML, MS Office Suite-Excel Macros, Project, Visio, Adobe Photoshop, Flash, Rational- Rational Rose, Rational XDE.

PROFESSIONAL EXPERIENCE:

Confidential, Huntsville, AL

Business Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Developed gap analysis and risk assessments for theFACETSupgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Successfully used Agile/Scrum Method for gathering requirements and facilitated user stories workshop. Documented User Stories and facilitated Story Point discussions to analyze the level of effort on project specifications
• Knowledge of Medicaid Information Technology Architecture MITA Service Oriented Architecture (SOA)
• Involved in gap analysis and implementation of HIPAA 5010, ICD10 and Claim Validations
• Designed, developed and maintained system configurations, such as Procedure Codes, Pay Codes, Payor/Benefit Plans, Follow-Up Workqueues, Charge Entry and Claim Edits
• Support for, and documentation of, required changes to business processes in connection with ACA ( Affordable Care Act)
• Published detailed guide describing data file content and structure for business partners; created quick reference guide for HIPAA EDI ASC X12 834 transaction set for Medicaid enrollment.
• Translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) in an SOA environment
• Created process flow for moving the claims related data from EDW to EDM.
• Tested claims adjudication and group and enrollment in Amisys for New Medicare advantage members.
• Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared Business Requirement Documents (BRD) using Rational Requisite Pro.
• Performed Gap Analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
• 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 inFACETS.
• Performed testing forMedicare, MedicaidandX-Over claimsforMedicaid Management Information System (MMIS)
• Involved inclaim adjudicationprocess of facets application
• Worked extensively through Agile development methodology by dividing the application into iterations
• Supported SOA, data warehousing, data mining, and Enterprise Service model standards in designs, and developed standardization of processes like configuration management
• Worked on customizing the claim module ofFACETSfor repricing Nursing home claims.
• Involved in testing the ICD-10 codes by sending the test transactions to clearing houses or payers
• Deep understanding of all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Data mapping on Enrollment Module (EDI 834) ofFACETS.
• Used MQ test and SoapUI for XML response for the member information from Siebel GUI interface purpose and WSDL files uploaded in SoapUI testing using client security certs.
• Extensive analysis on conversion of Claims, Members and Providers files from Amisys.
• Coordinated testing for contract set-up, enrollment and claims processing for four new managed care contracts for Medicaid mental and physical health providers.
• Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Inspected and worked on HTTP web services application and on SOAPUI
• Analyzed the functionality and came up with test scenarios for split-billing process onFACETS.

Environment: Windows 2000/XP, MS Office, SQL Server, Agile, Oracle, MS Project, MS Access, XML, TestDirector, LoadRunner, Rational Rose, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential, Bluebell, PA

Business Analyst

Responsibilities:

• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Gather detailed business and technical requirements and participate in the definitions of business rules and data standards.
• Acted as a liaison between client and payer/intermediary. Experienced in payer rules, requirements, governmental regulations and HIPAA compliance.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Worked on MITA to upgrade the existing MMIS and also conducted mapping for EDI transactions
• Strong knowledge of web services testing using SoapUI, XML.
• Been a part of Architecture and modeling team and have used SOA (Service Oriented Architecture)
• Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
• Managed the systems development and built the business processes to activate Medicare parts A-B-C & D, Special Needs Programs (SNP) and Private Fee For Service (PFFS) plans on FACETS version 4.41 platform.
• Responsible for the use of scarce resources through the development and sharing of reusable software making use of (Medicaid Information Technology Architecture) MITA.
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Gathered the Requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act(PPACA).
• Analyze Business Requirements (BRD) and translated them into Functional Requirements (FRD or Use Case Model)
• Extensive experience in Data Analysis and ETL Techniques for loading high volumes of data and smooth structural flow of the data.
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Defined Business Process aligns with Company goals and existing HIPAA regulation to communicate with CMS Programmatically from Amisys system.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• FacilitateSystem Integration Testingon FACETS systemtoverify HIPAA compliance from 4010 to 5010.
• 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) andCDA (Clinical Development Analytics). Healthcare Domain Knowledge with SQL knowledge (in Oracle environment) and 5010, ICD-10 experience.
• Ensure data integrity through effective configuration of fields and tables; proficiently review and correct 837 rejected files as well as evaluate 835 files to determine optimal solutions for creating payor matches.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Preparing BRD, Business Cases, and presentation to the clients, Business Re-engineering proposals.
• Deflected the impact of multiple report requests from the Business Intelligence users.
• Design, develop and went live after migrating several MS Access & SQL Server databases for corporate developers, resolving typical database issues.
• Captured all HIPAA-related EDI data in the repository using FACETS.
• Defined Business Process aligns with Company goals and existing HIPAA regulation to communicate with CMS Programmatically from Amisys system.
• Established traceability matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.
• Interpreted legal and financial payor-provider contracts between healthcare practices and health insurance providers surrounding the methodology and rates of insurance reimbursement.

Environment: Ascential DataStage, (Designer, Director, Manager, Parallel Extender) Debugger, Oracle, MS Word, Excel, Visio, Access, and Project, Mercury TestDirector Agile, Waterfall.

Confidential, Pittsburgh, PA

Business System Analyst

Responsibilities:

• Understanding the current business process, defining scope of the project along with vision statement.
• Met with users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
• Applied Unified Modeling Language (UML) methodologies to design Use Case Diagrams, Activity Diagrams and Sequence Diagrams in Rational Rose.
• Established RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
• Worked with Data Extraction, Transformation and Loading (ETL).
• Wrote the SQL queries on EDW tables and Data Mart Staging Tables to validate the data results.
• Accepted inbound transactions from multiple sources using FACETS.
• Looked up ICD-9 codes to verify if a code has been changed and entered deposited and updated patients\' demographics using the Medisoft system and ePACES online system to verify a their Medicaid status.
• Develop Conceptual Data Model & Logical Data Model in alignment with MITA Information Architecture.
• Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277, 278 837P, 837I, 837D, 835 remittances)
• Coded the ETL and Business Intelligence Batch and On line PL/SQL Packages.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagramsso that developers and other stakeholders can understand the business process.
• Assure that all Artifacts are in compliance with corporate SDLC Policies and guidelines
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Supported integrated EDI batch processing and real-time EDI using FACETS.
• Direct contact with the payer on behalf of the provider to discuss claim rejection reasons concerning claims and enrollment
• Wrote the BRD, completed the walkthrough, and delivered the final version to the team.
• Solid experience in Claims Processing 837 transactions and remittance 835 EDI files
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Parsing high-level design specification to simple ETL coding and mapping standards.
• Designed and facilitated the implementation of data warehouses required by application systems.
• Automated Shell scripts to pull and load data from operational resources into the Data Staging Area and Data Warehouse for business intelligence reporting
• Worked on the HIPAA 4010 conversions and worked on the EDI 834, 837, 835 and 278 files and validated the functionality according to the new HIPAA 4010 changes.
• Performed cost-benefit analysis, generated reports for analyzing various investments and their profitability and also for analyzing various lost opportunities due to time delay in investing.
• Validated business rules and all artifacts with users, approval and sign off.

Environment: Windows, MS Office(MS Word, MS Excel, MS Powerpoint, MS Visio), Crystal reports, RUP, UML, Visual Basic, SQL, Win Runner

Confidential, Milwaukee, WI

Business Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• 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.
• HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Gather final requirement and draft the BRD and Business Data Flow Diagrams
• Well versed with HIPAA, Facets, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 837, and HIPAA EDI Transactions across enterprise.
• Analysing the ETL process created in Informatica, developed SQL queries and tables which replicated the ETL, and compared the SQL results with the Informatica tables.
• Involved in creating sample mappings for the conversion ofEDI X12transactions code sets version4010to5010and translation ofICD 9codes intoICD 10codes.
• Create scope documents, business requirement documents (BRD), application requirement documents (ARD), use cases, UAT scripts, current and future state process flows and wireframes. Create work breakdown structure for analysis timeline.
• 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.
• Used Query Analyzer, Execution Plan to optimize SQL Queries
• 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.

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