SUMMARY

• More than 7 years of experience as Business System Analyst with expertise in Business Analysis Business Process Analyses, Requirements gathering and management of documentation in Healthcare, Insurance and Retail domains.
• Extensive knowledge of industry standard methodologies such as SDLC and have anexcellent experience in all phases of Waterfall, Agile and RUP.
• Skilled in the areas of writing Business Requirements Document (BRD), Functional Specifications Document (FSD), System Requirement Specifications (SRS) and Requirement Traceability Matrix(RTM).
• Facilitated JAD sessions for requirement gathering and requirement clarifications.
• Strong Experience of working in Medicaid and Medicare Part A,B,Cand D, PPO,POS and HMO health insurance plans
• Experienced working on Electronic Data Interchange (270, 271, 834, 835, and 837) transactions in compliance with current HIPPA regulations.
• Well versed with Health insurance standards such as HIPAA 4010/5010,ICD - 9/ICD-10, MMIS, MITA framework and HL7messaging standards.
• Experienced in working with HIX system in the transmission of Health care related data between providers and payers
• Skilled at performing GAP Analysis, Risk Analysis,Cost Benefit Analysis along with good knowledge process workflow tools and techniques
• Executed SQL queries and stored procedures manually for back-end testing.
• Developing and Maintaining Test Scripts, analysing bugs and interacting with development team members in fixing the defects.
• Worked in ETL environment involving Informatica /Data Stage.
• Well versed in preparing Test strategies, Test plans, Test cases, Test scripts, Defect reports using HP Quality centre and other Testing tools.
• Worked on FACETS Claims processing application module.
• Quality Assurance experience including development of Use cases, Test plans, Test cases, Test scenarios, performing Regression Testing and Incident tracking.
• Worked on Rational Quality Manager (RQM) to track, schedule and execute the test cases.
• Conducting User Acceptance Test (UAT) and verifying performance, reliability and Fault tolerance issues.
• Excellent interpersonal skills, proven team player with an analytical bent to problem solving and delivering solutions under high stress environment.

TECHNICAL SKILLS

Languages: SQL, Visual Basic

Tools: Quality Center, QTP, MS Office

Database: MS SQL Server 2005/2000,MS Access

Business Analysis: SDLC, Critical Thinking, Decision Making Strategy, Analytical thinking, Use Case Analysis, Requirement Analysis.

Documentation Tools: MS Project 2000

Operating Systems: Windows 2000/2003/2007/ XP

PROFESSIONAL EXPERIENCE

Confidential, Milwaukee, WI

Sr. HIX Business Consultant/Sr. Business Analyst

Responsibilities:

• Facilitating the Enrollee Satisfaction Survey Vendor Contracting Oversight, Health care issuer Accrediting Entity Management, Health Plan Issuer Accrediting Verification for the FFE Quality Team
• Developing Health Plan Issuer Accreditation Mapping to Qualified Health Plan (QHP)
• Participating in workshops and update meetings with Insurance carriers
• Facilitating the requirements sprints for the FFE Financial Management Team and Advance Premium Tax Credit (APTC).
• Conducting Claim/Encounter Management, claim data collection, claim quality check, and filter claims for Risk Adjustment.
• Facilitating Cost Sharing Reduction (CSR) Reconciliation and reporting, Federal Exchange, Qualified Health Plan (QHP) User Fee, Risk Adjustment Claims processing, Risk Adjustment Factor calculation, Risk Adjustment Annual Issuer Charge and Payment, Risk Adjustment reporting, Risk Adjustment User Fee, Reinsurance Contribution (Issuer, State and TPA), Reinsurance Quarterly payment calculation and reporting.
• Conducting Stakeholder Analysis.
• Facilitating Health Insurance Form Filing requirement sessions.
• Developing Preliminary Business Object Model for Health Insurance Form Filing, Requirement Document for Health Insurance Form Filing and Preliminary Business Process Model for Medical Loss Ratio (MLR) CD Administration.
• Write and maintain project requirements, facilitated meetings, built business and system flows, managed defects and wrote test scripts and use cases.
• Responsible for providing Business Requirement Document (BRD) and Functional Requirement Document (FRD)
• Creating of Business Process Workflow Diagrams with Stakeholders throughout the Business System Development Life Cycle (SDLC), to create the provider portal which allows providers to access Confidential t information to increase convenience.
• Involved inrequirements gathering sessionswith Business Analysts and Architects tounderstand requirements in terms of business change.
• Successfully using Scrum Analysis Model (Agile) for gathering requirements by facilitating Use Case Workshops and sessions.
• Providing subject matter expertise for the implementation of Health Exchange Business Process with a special focus on Medicaid Integrated Eligibility, Plan Management, SHOP/SHOPPING, and Financial Management Business domains.
• Following the Agile scrum SDLC (System Development Lifecycle) methodology, Validated QHP Benefits, Rates, Network Adequacy, Essential Community Providers, Prescription Drugs and Service area Information with their templates for data submission by insures.
• Validating system requirements for the Certifications, Accreditations and Attestations of Insurance Carriers and system integrations with the Department of Insurance (DOI). The SERFF system and the CMS-HHS Federal Hubs.

Environment: Share Point 2010, Industry Print 5, MS Visio 2010, SQL

Confidential

Business Systems Analyst

Responsibilities:

• Conducted GAP Analysis for current Medicaid Management Information System (MMIS) and federal mandate HIPAA 5010 / ICD-10.
• Assessed HIPAA 5010 requirements by creating Side By Side Business Rule Comparison documents for State specific Interface Record Layers (IRL) using ASC X12 Standards 5010 implementation guide for all transaction.
• Briefed System Analysts about the changed/added/deleted Business Rules for HIPAA 5010 and project details.
• Analyzed System Impact including MMIS Tables, Windows, Reports and Interfaces to external entities.
• Analyzed Medicaid Eligibility Determination System for Children’s Health Insurance Program (CHIP) and enrolment transaction 834 submitted to program administrator for HIPAA 5010.
• Analyzed HIPAA 5010 impact on external data warehouse and data warehouse extract process and mapping of MMIS database and data warehouse.
• Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.

Environment: MS Office Suite, Agile, Oracle, SQL, Windows XP, Quality Center, Java, Java Script, Win Runner, Business Objects, MS Visio, FileNet, Rational Clear Quest, Rational Clear Case

Confidential, TX

Business Systems Analyst

Responsibilities:

• Gathered and documented business requirements for the enhancements related to eligibility and benefits application for providers and Members as input for Functional Requirements Specification (FRS).
• Created activity diagrams and sequence diagrams using MS Visio to communicate the system activity flow to the Dev team and QA team.
• Perform a baseline assessment and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
• Ensured HIPAA compliance related to display of minimum benefit information that the Provider is required to pass on the EDI transactions.
• Conducted analysis of HIPAA compliance and took part in discussions for designing the healthcare transactions to be HIPAA 5010 compliant.
• Identified risks, problems, requirements and concerns to comply with ICD-10 changes.
• Involved in mapping and validation of different EDI transaction used for claims filing like 837 (I, P, D) for claim submission, 270/271 for the eligibility/benefit inquiry and response, 276/277 for the claims status enquiry and response and 835 for the healthcare claim payments.
• Involved in mapping data from different EDI files onto database using different routing transformations..
• Have strong experience in requirements gathering by conducting interviews with end users.
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.

Environment: MS Project, SQL, Rational Unified Process (RUP), Rational Requisite Pro, Rational Rose, Clear Quest, Microsoft Visio, Windows 2000/XP, Mercury Test-Director, MS Visio, Business Objects

Confidential, Coraopolis, PA

Business Analyst

Responsibilities:

• Worked as a Business Analyst, interviewing clients to understand their business and functional requirements, gathering their future needs and transforming them to functional specifications.
• Involved in interviewing Subject Matter Experts (SMEs) and carefully recording the requirements in a Business Requirements Document (BRD).
• Documented requirements, defined scope and objectives, and formulated systems to parallel overall business strategies.
• Created Screen designs for the development team to ensure client’s requirement were adequately represented.
• Performed gap analysis between the “As-Is” model of the legacy system and the “To-Be” model to identify the gaps, logged issues relating to the identified gaps and worked with the SME to get clarifications.
• Created Use Case documents and Process Flow diagrams using Microsoft Visio for all System Functionalities.
• Followed UML based methods using Rational Rose to develop Use Cases; assisted developers in creating sequence diagrams and Activity diagrams.
• Involved with regular walkthroughs and meeting to discuss bottlenecks in the system and possible solutions with the development team.
• Performed report validation writing SQL queries using TOAD on an SQL Server database.
• Prepared and maintained Requirements Traceability Matrix.
• Followed formal test plans to ensure the delivery of quality software module by performing Grey box testing.
• As a key member of the Quality Assurance team was involved designing test plans, test cases, test results analysis and conducted reporting defect management and test status matrices.
• Tracked change requests and monitored workload and schedule.

Environment: Windows XP/7/8, MS Word, MS Excel, MS outlook, MS PowerPoint, MS Project 2010, MS Visio, Rational Rose, SQL Server, MySQL, Load Runner, Quality Center

Confidential, WINSTON SALEM, NC

Business Analyst

Responsibilities:

• Worked as one of the main liaison between the business line, operations and the technical areas throughout the project cycle.
• Assisted the Senior Business Analyst in drafting business requirements, functional requirements and As-Is and To-Be document.
• Evaluated prior documentation of the existing system and reviewed logged experience of the end users.
• Participated in Joint Application Development (JAD) sessions and reviewed meetings with the users and development team to ensure understanding of the new functions.
• Worked closely with the development team to ensure viability of new features to ensure proper functionalities.
• Coordinated project activities with project manager and various other teams.
• Produced detailed design specifications using Use Case Diagrams/Scenarios and Activity Diagrams.
• Performed GAP analysis of existing system and evaluated benefits of the enhanced functionalities.
• Prepared prototypes and User Interface Diagrams for users and the development team to illustrate the intended functionalities of the system.
• Involved in walkthroughs and meetings with the development team.
• Acted as User Acceptance Testing (UAT) coordinator and monitored business testing and interfaced with the development team regarding defect status and fixes on daily basis.
• Tracked and maintained user requested enhancements and changes.

Environment: Java, J2EE, IBM Mainframe, Quality Center, Smart Draw, MS Word, MS Excel, MS Windows XP

Confidential, Philadelphia, PA

Business Systems Analyst

Responsibilities:

• Responsible for defining the scope of the project, gathering business requirements, doing gap analysis and documentation.
• Articulated business requirements from user interviews and then converted requirements into technical specifications
• Developed data validation program for HIPAA transactions
• Created the as-is and to-be process flow diagrams based on the current system features and the stakeholder’s needs.
• Designed Connection Models for Validation and transformation of HIPAA transactions using EDI Source and HIPAA Model.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped..
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
• Worked with technical experts to prepare test case scenarios for unit testing, integration testing, user acceptance testing and compliance testing.
• Developed ETL logic to transfer data from systems to the Data warehouse environment using the available ETL code and tool set for implementation.
• Assisted with user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
• Provided SME support to the development and testing teams.

Environment: SQL Server, Rational Suite tools, MS Visio, MS Project, MS Office (MS Word, MS Excel, MS PowerPoint), MS Access.