PROFESSIONAL SUMMARY

• Over 8 years of professional experience as Business Analyst with expertise in Software Development Life Cycle SDLC and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Extensive experience in the development, implementation and integration strategies towards a team oriented environment, utilizing quantitative and qualitative analytical skills. With ease in communicating/converting clients vague/non-technical requirements into precise/concise representation to the team.
• Experience in developing detailed functional specs through JAD sessions, interviews, on site meetings with business users development team.
• Documentation: BRD Business Requirement Document , FRD Functional Requirement Document and Non-functional Requirement Document.
• Experience with PMO techniques such as Rational Unified Process RUP , Agile Waterfall life cycle
• Experience in interviewing Business users SME providing recommendations to resolve issues for various business/technical groups defining strategic solutions to business problems in a multiple project environment.
• Test Case writing manual/automated test cases and Conducting Tests Integration testing, Regression testing , Black Box/White Box testing, UAT User Acceptance Testing .
• Analysis Design Use Case, Sequence and Activity diagrams .
• Writing Manuals System guides, training material for business users and Deployment guides .
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with data analysis, data mapping and dimensional modeling experience in decision support systems data marts using Star Schema.
• Good knowledge on different modules within health-care Membership, billing, enrollment, claims, capitation, providers .
• Knowledge of Electronic Medical Record EMR and Electronic Health Record EHR
• Knowledge in Health Care Reform and Patient Protection and Affordable Care Act PPACA
• Experience with HIPAA compliance 4010 5010 and Health care systems
• Experience with Medicare, Medicaid, Medigap/Medsupp commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes NSF formats for interfaces images to clearinghouses/ trading partners applications.
• Experience with health care Systems: FACETS, Medicare Part A, B, C, D, Medicaid systems.

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business Analyst

Responsibilities:

• Worked with Delegates/vendors for the entire project of ICD 10 in UCare. Dealt with internal and external representatives to capture requirements.
• Created Test cases using excel sheet and implemented the test cases in the test environment.
• Researched data using SQL queries to capture and analyze back end system. Mapped the ICD 9 codes to the corresponding ICD 10 Procedure and Diagnostic codes.
• Tracked all the report, files and extracts exchanged between Vendors. Identified the location, purpose and requirement change after the ICD 10 updates are performed on the data.
• Captured the requirements for ICD 10 changes in the EDI 837 P I X12 file.
• Used the companion guide and coordinated with the internal and external teams to capture detail loops and segment for the ICD 10 updates.
• Analyzed defects and issues using Microsoft Access Database as the front end system for Disease Management/Customer service team.
• Responsible for writing test cases and implementing them for the Business team.
• Gathered Reconciliation requirement and created Business Object Report spec for the internal Disease Management team.
• Co-ordinated with test leads of various projects to make sue relevant defects were logged in and fixed by the development team. Updated BRD's based on the defects identified by the Team.

Environment: Waterfall, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL.

Confidential

Sr. Business and Solution Analyst

Responsibilities:

• Conducted gap analysis, create project charter and LOE Level of Effort to identify the budget of the project and request for approval.
• Conducted JAD session with business people, stakeholders, SMEs, developing team as well as QA teams to gather high level requirement and in the meantime discuss with Dev team and QA team about the requirements' feasibilities according to the system using Agile, Scrum Methodology.
• Created work packages, task lists and schedule meetings with different group such as Business side, development side, QA and core project team to begin with HLR High Level Requirement gathering and HLD High Level Design session.
• Gathered and reviewed HLR High Level Requirements and DLR Detail Level Requirements and send to business people for approval as well as Included context diagram, activity diagram, high and low level business process flow as well as decomposition diagram to make clear understanding about the proposed business processes as well as interface system.
• Create and propose new business process model and process improvement logic and ideas.
• Created and reviewed HLD High Level Design and DLD Detail Level Design included logical and physical diagrams, sequence diagrams by using MS Visio and send to technical people for approval.
• Scheduled weekly meeting with core project team and discuss about different problems if there is any and on the basis of identified problem, we find out the appropriate solution.
• Created and maintained PTR Project Traceability Matrix so find out what is the current phase, delivery date, extended delivery date, issues related project and various follow up.
• Created change request to change management department if there is any requirement include or exclude.
• Collected different screen shorts and created new ware frames, mockups and prototypes for the project and introduce those wire frames to the team as well as business and technical team to develop those wire frames into the web services.
• Communicate with developers and QAs to collect information about their release schedule and make them understand about various artifacts.
• Managed offshore developing team for several project as well as create budgeting on the basis of their effort, did meetings, solved issues if there any.
• Used Share Point for uploading, editing and deleting new and existing document to the team members.
• Worked on Medicare and Medicaid clams for PBM Pharmacy Benefit Management . Identified different Medicare Part D and Medicaid plans and procedures for claim adjudication and provide various claim process as well as focused on ICD 9 to 10 conversion, HIPAA, other Drug claims and adjudication.

Environment: Agile Scrum, Microsoft Office Suite, Smart Draw, MS SQL 2008, HP Quality Center, MS Share Point, MS Visio, MS Office, MS Project.

Confidential

Responsibilities:

• Analyzed the Plan Data Database using SQL Server. Surveyed and examined the current documentation.
• Gathered and documented business requirements from SMEs, user groups and vendors via workshops, interviews and JAD sessions.
• Co-coordinating with the team to analyze the 834, 835 and 820 EDI Transactions for dual eligibility Project FTC .
• Prepared the Functional requirement for the automation of 834 and 820.
• Analyzed the level of HIPPA Validations for the EDI transactions. Worked with the Solution architect on the approach to correct the current errors in the HIPPA validation.
• Using Process flows and Use Case diagrams to demonstrate AS IS and TO BE state.
• Worked in close collaboration with the Project Manage and IT team.
• Created and gathered requirements for the Vendor. Helped PaySpan to create Data Mapping document for the EFT, 835 and Remittance Advise sheet.
• Gathered and documented requirements for EFT Project for PaySpan Third Party Vendor .
• Coordinating with the QA team to create UAT test cases.
• Participated on cross-functional teams developing new or enhanced systems processes, procedures and policies.
• Provided project status reporting, updating of project information, effort resource estimating.
• Effectively established and maintained working relationships with peers and constituents.
• Produced various artifacts Functional Requirement Specifications FRS and User Requirement Specification URS .
• As a point person responsible for resolving business rules/conflict resolution for the development team.

Environment: Waterfall, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL.

Confidential

Business Analyst/System Analyst

Responsibilities:

• Gained understanding of HIPAA 4010 versus 5010 and ICD-9 versus new ICD-10 code sets. Studied and analyzed the conversion information provided by the CMS Centers for Medicare Medicaid Services .
• Prepared Business requirement document BRD using Rational RequisitePro.
• Performed gap analysis for 4010 to 5010 Upgradation.
• Worked on EDI transactions 276 claim inquiry , 277 claim response , 837 Institutional and Professional claims and 834 enrollment .
• Went through the companion guide of the organization to understand the 837 and 834 segments used by the organization to identify the ones that need to be changed.
• Worked with the SMEs to convey the modifications that need to be made and the processes and systems affected by the same.
• Extensively used SQL queries to retrieve data for testing and analytics.
• Interpreted the ICD-9 to ICD-10 and reverse translation logic fully understanding the GEM General Equivalence Mappings for ICD-10 CM and ICD-10 PCS.
• Understood complete claims processing cycle from the payer/provider perspective and the processes impacted by the conversion to ICD-10.
• Performed impact assessment for complete application inventory using Microfocus a tool for impact analysis and application remediation worked with the business team to identify business challenges, risks, opportunities and corresponding mitigations.
• Assisted the development team with the design and implementation of the ICD-9 to ICD-10 GEM crosswalk tool. Executed manual test cases to confirm the logic was implemented as desired.
• Participated in weekly meetings and walkthrough's for project updates to detect bottlenecks and devised plans to handle the bottlenecks.
• Facilitated the overall management of the project by collaborating with the team, providing weekly status reports and delivering presentations.
• Analyzed ICD-10 project readiness and recommended best practices for ICD-10 transition based on research conducted.
• Worked with the team to create a project road map/blueprint ensuring effective remediation of all applications that participate in the ICD-10 transactions

Environment : COBOL, GEM, MS Visio, Rational Rose, MS Office, SQL, Oracle, PowerPoint, MS Word, MS Excel, SQL, PL/SQL, ETL, ERWIN, UNIX, Windows

Confidential

Business Analyst

• Prepared specifications for enhancements to the existing application by using existing legacy system documentation and procedures.
• Interacted extensively with End users in Underwriting, Claims Processing teams and Subject Matter Experts SME's in order to obtain the business needs and requirements.
• Organized, Facilitated and managed meeting sessions with major stakeholders and users in order to review business requirements.
• Prepared Business requirement document BRD using Rational RequisitePro.
• Analyzed the business requirements and designed work flows in order to communicate to the major stakeholders how the system would be realized in the implementation phase.
• Interacted extensively with technical and development teams in order to ensure clear understanding of expected functionality, process flows and navigational flows of the new application.
• Assisted in EMR system implementation to enhance full two-way interoperability between Insurance Company and Physicians. Optimized training documentation prior to go-live.
• Documented system work flows and executed EMR training plans for staff that led to significant increase in EMR usage from 35 to 80 .
• Work with IT Development and QA staff to improve and customize the EMR application.
• Defined test cases, created test scripts and interacted with QA / development teams in identifying and resolving errors and in User Acceptance Testing UAT .
• Actively participated in high level meetings with users and stakeholders to identify problems areas, resolve issues and improve the process in order to ensure an accurate and stable solution.
• Implemented the Rational Unified Process RUP to implement iterative SDLC. Developed RUP Analysis Model that included entity classes, use case diagrams, sequence diagrams in order to provide an accurate view of the requirements.
• Followed the Standard Operating Procedure SOPs of the company in documenting Test Plans, Test Cases and Test Procedures using Business requirements document and Functional requirements document of the system.
• Managed project progress by measuring against milestones, managed resource allocation, tracked project activities, resolved bottlenecks, published status reports and recommended actions.

Environment: MS Visio, Rational Rose, MS Office, SQL, Oracle, PowerPoint, MS Word, MS Excel, UNIX, Window

Confidential

Business Analyst

Responsibilities:

• Involved in requirement gathering, conducting requirement review meetings and working with other cross functional teams to maintaining the project plan
• Gap Analysis of business requirements, generated workflow process, flow charts and relevant artifacts.
• Defined and documented the vision and scope of the project.
• Developed Process Model and detailed Business Policies.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Performed manual testing on different modules of the application.
• Developed Test Matrix to give a better view of testing effort.
• Verified that the data outputs and transformations between systems remain true and not compromised as systems are bundled together.
• Participated in various meetings and discussed Enhancement and Modification Request issues.
• Attended weekly meeting to discuss progress and modification to test plans due to change in business requirements.

Environment: Microsoft Office suite, Rational Requisite Pro, Rational Rose, Microsoft Visio, Clear Case, UML, Quality Center, Oracle, JAVA