PROFESSIONAL SUMMARY

• Healthcare Business Analyst with 7 years of experience in HealthCare, Insurance and IT based Industries.
• Expertise in documenting the Business Requirements Document BRD , developing the UAT Plan, maintaining the Traceability Matrix and assisting in Post implementation activities.
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and UML concepts.
• Excellent understanding of HIPAA 5010 and ICD -10 initiatives.
• 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 X12 4010/5010 transaction sets: 270/271, 276/277, 834, 835, 837 Professional Institutional claims
• 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.
• IFX Web Portal gathered requirements for the Referral Web Portal to be used by various business areas.
• Created Use Cases and Process Flow diagrams for the Referral Web Portal. Analyzed current and future processes for the portal.
• Expertise in working with Claims NASCO , Provider, Enrollment, finance, benefits and Vendor Management Business Areas.
• Expertise in analysis of healthcare claims, use of ICD 9 diagnosis codes and CPT codes.
• Experienced in Implementing Normalization/Renormalization techniques for optimum performance in OLTP/OLAP database environments.
• Mercury Test Director Expert in all phases of Defect / Bug Fixing. Experience in building test plans and test cases and navigating through the test lab.
• Defect Management / Bug Fixing Fully involved in the process of defect identification and resolution using tools like Test Director, Clear Quest and Quality Center.
• 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

WORK EXPERIENCE

Confidential

Business Analyst

Responsibilities:

• Gained subject matter expertise on the Claims Adjudication Process and gathered and documented end to end requirements
• Experienced in receiving, analyzing and adjudicating Medical and Pharmacy claims within Central Bill Processing System CBP
• Facilitated Design Sessions to gather requirements for Bill Adjudication/ Processing and creating Design Specification Document
• Used various Methodologies and Pricing Logic in creating Design and Functional Specification Documents for Bill Pricing
• Facilitated Design Sessions to gathered requirements for Edits and Audits and Treatment Suites - for validating Claimant and Provider Eligibility and understanding the concept of Authorization level and providing Explanation of Benefits EOB messages on Remittance Vouchers, RV's.
• Gathered requirements during Design Sessions and created Functional Specification Document FSD for Pharmacy Claims.
• Created Functional Specification Document FSD and Functional Requirement Document FRD
• Developed Use cases, Use case diagram, Activity diagram, and other flow charts to create Functional Specification Documents.
• Facilitated sessions with end user, expert team, business intelligence team, SME's, development team, testers, QA team, walk through and Signoff from Department of Labor, DOL as required
• Provided input into the development and modification of systems to meet client needs
• Coordinated meetings with clients on larger accounts to gather and document requirements and explore complex solutions
• Traced business requirement changes and maintain a Requirements Traceability Matrix RTM to keep Department of Labor, DOL informed of the progress of the project
• Created and managed project templates, use case project templates, requirement types and traceability relationships on SharePoint
• Created Use Case Diagrams, Activity Diagrams and Sequence Diagrams in MS Visio

Environment: Share Point, MS Visio, Microsoft Excel, Microsoft Word, Microsoft Power Point.

Confidential

Business Analyst

Responsibilities:

• Created Business Requirement Document BRD and Functional Requirement Document FRD
• Created Use cases, Use case diagram, Activity diagram, and other flow charts to define the business process
• Experienced in facilitating of Joint Application Development JAD sessions with end user, expert team, business intelligence team, SME's, QA team, Walk Through and Signoff with Stakeholders as required
• Extensively used tools like Microsoft Excel, Access, Share point, MS Visio and in-house Optimal Trace tool
• Facilitated JAD Joint Application Development sessions to resolve issues relating to difference between business requirements and technical design
• Extensively used Optimal Trace Home grown system to document BRDs FRDs
• Supported change control of projects that comes in during or after the project being implemented.
• Created Use Cases to make developers understand the requirements in more easy way
• Strong experience in RUP and Agile Business Modeling process, complete UML artifacts related to Business Modeling and Requirements, including MS Visio and Rational Rose
• Served as a liaison between the Subject Matter Experts SMEs and the project team to define frameworks for the development
• Translated Business requirements and functional specifications into Scenarios to make developers understand the requirements in more easy way
• Captured process flows by preparing activity and sequence diagrams, pre- and post-conditions, performance requirements, impacted areas, high-level business rules, issues, areas in scope and out of scope, assumptions, etc.
• Worked with SCRUM Methodology
• Worked on Sprint Methodology, using for new projects like Custom Faxing, Auto faxing elaborating Epic stories and Acceptance Criteria to create flow
• Reviewed Technical Specification Documents, TSD, with development team, resolves issues and provide Sign Off
• Reviewed QA test case outputs for all projects undertaken

Environment: Optimal Trace, Share Point, MS Office Suite, MS Visio

Confidential

Systems Analyst

Responsibilities:

• 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.
• Lead a team of 4 business analyst and reviewed their artifacts.
• Created Gap/Impact Analysis Document for the Prescription Drug Point of Sale System
• Created Gap/Impact Analysis Document for the Drug Utilization Review System
• Met and gathered requirements from EDI services, NASCO, QBLUE, MTM Audit, HIPAA 5010 team, E-Services, NMS 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, 278R, 835 reports and screens, 278A reports and screens, 278R reports and screens, 276/277 reports and screens and common reports and screens BRD.
• Reviewed SIT test cases and created defects to add and update the test cases.
• 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

Confidential

Business Analyst

follow:

• Understanding and assessment of the current EDI Transactions used
• Understanding and assessment of the current Pharmacy Transactions from an NCPDP 5.1 perspective
• Understanding and assessment of the current ICD 9 codes used by the State
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions 837, 835, 276/277, 270/271
• Creation of a Gap/Impact Analysis Document for changes to Pharmacy Transactions real time and batch based on NCPDP 5.1 to NCPDP D.0 , specifically concerning the data elements
• Creation of a Mapping Document for ICD9 Codes to ICD 10 Clinical Modifications and Procedural Codes.
• Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System
• Creation of Gap/Impact Analysis Document Operational Analysis Document for the Drug Utilization Review System
• Creation of Gap/Impact Analysis and Operational Analysis Document for Medicaid Subrogation
• Creation of Gap/Impact Analysis Document and Operational Analysis Document for the Drug Rebate Analysis and Management System

Environment: MS Office Suite, MMIS, POS, GEMS, Document Analyzer, Sharepoint

Confidential

Business Analyst

Responsibilities:

• Gathering and documenting of business requirement to support key enterprise projects and project team members.
• Identify and promoting process improvement opportunities for gathering requirements.
• Create and maintain Requirement Traceability Matrix RTM and Customer Requirement Template CRT for each of the assigned project.
• Developed 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 MCO and 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.
• 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

Sr. Business System Analyst

Responsibilities:

• Interviewed business users, SMEs, Trading Partner asking detailed questions to gather business requirements, wants, and needs concerning the project and carefully recorded the requirements in a format that can be understood by both business and technical teams.
• ITS and CARE data is maintained in IMS.
• Involved in Testing of ITS Software.
• Involved in database conversion on IMS to DB2 ITS 10.0
• Transferred claim files using NDM Network Data Mover technology. Development of maps as per mapping specifications or as per HIPAA implementation guide.
• Analyzed the root cause for batch job failures and online application failures and take the appropriate action to avoid the batch delays.
• Worked on modules related to creation, modification of member and provider.
• Dealt with 834 import member lookup processes and resolving issues with member attributes, enabling multiple rules associated with member lookup process in FACETS 4.3.
• Used Process log browser to view different types of log history files to figure out issues with 834 transactions.
• Responsible for working with Core Team to review and modify process flows to increase productivity and effectively utilize FACETS 4.3 features not provided by the legacy systems.
• Attended daily SCRUM and guided QA and Developer regarding the defects, Technical Specification Documents and Mapping Documents.
• Coordinate with the data conversion team and Trading Partner during the development, test, and reconciliation process and post implementation FACETS 4.3 and legacy systems data to ensure accuracy and consistency.
• Worked with ICD 9 encoding to verify the validity of incoming claims, documented ICD 9 codes presently used by the system.
• Troubleshoot any problems found within FACETS 4.3 and when testing the SQL data database while validating against the business rules.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML.
• Implemented Traceability Matrix and Business Requirement Specification Document verified the functionality coverage.
• Heavily involved with SharePoint in uploading, and arranging documents.
• Assisted informational needs in mapping of Test Cases.
• Supported the business and the technical team in the product development and delivery process and successfully managed cross- departmental relationships.
• Created, implemented and manage the Change Control process for all system associated development related to the FACETS 4.3.
• Coordinated with QA and user acceptance testing.

Environment: MS Project Plan, MS Visio, MS Office, MS Access, ClearQuest, SharePoint, COBOL, DB2, VSAM, Unix scripts, OLTP, Cognos, Informatica Data stage. FACETS 4.3

Confidential

Business Analyst

Roles and Responsibilities:

• 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.
• Interacted with the End-Users by interviewing them, by preparing appropriate questionnaire to better understand end-user needs and the business process.
• 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.
• 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.
• 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.

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