Objective

• More than 5 years of professional experience as Sr. Business Analyst/Solutions Architect and Project Manager in the Health Care sector
• Expertise in Software Development Life Cycle SDLC and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, billing, 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 healthcare Membership, billing, enrollment, claims, capitation, providers .
• Knowledge of Electronic Medical Record EMR and Electronic Health Record HER
• Knowledge in Health Care Reform and Patient Protection and Affordable Care Act PPACA
• Experience with HIPAA compliance 4010 5010 and Healthcare 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.

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

Responsibilities:

• Worked as a point person responsible for resolving business rules/conflict resolution for the development team.
• Created 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.
• Performed deep analysis on the web service application and its current process.
• Designed and documented front end UI along with the Business and Design team.

Confidential

Sr. Business Analyst/

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

Responsibilities:

• Worked with delegates/vendorsfor 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.
• 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 sure relevant defects were logged in and fixed by the development team.Updated BRD's based on the defects identified by the Team.
• Created SOPs standard operating procedures for new service offering for consistency in delivery and clear performance expectations moved proof of concept program to launch ready state.
• Coordinated and conducted monthly meetings with cross functional teams to ensure projects were staying on task minimizing duplicate efforts while optimizing project resources.
• Facilitated requirements definition sessions for billing system with cross-functional teams to comply with business and regulatory mandates.
• Provided overall program status report to vice president and senior management on time and within budget delivery to assist in making better business decisions.
• Developed and managed project plans for each project, worked with multiple teams to identify task ownership and deadlines.

Confidential

Sr. Business Analyst / Business Solutions Architect

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

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 .
• 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.
• Modeling the enterprise and business landscape to analyze the alignment of business capabilities with delivered technology and IT solutions
• Collaborate with the business to evaluate business goals, identify business problems, and propose solutions
• Provide stewardship for the communities of practice surrounding all Enterprise Architecture disciplines i.e. Application/Systems, Information, Infrastructure, etc.
• Assist in setting standards and guidelines on how to unambiguously define and describe business and systemic requirements for information systems projects
• Provide leadership, decomposing business objectives, goals and Technology into an actionable set of project activities, to include Solution Analysis options and recommendations
• Provide clear direction on the projects execution assuring successful delivery of new or enhanced capabilities
• Mentor and coach peers in the lines of business on best practices
• Collaborate across other areas of the Enterprise Architecture team
• Facilitate open communication and fact-based decision making
• Facilitate change and process improvement within software development and business organizations
• Collaborate with quality teams to drive continuous improvement
• Research, identify, and recommend industry best practices for solving business problems

Confidential

Sr. Business Analyst

Environment:M2, Agile, Requisite Pro, MS Access, MS Visio, MS office, MS word, MS excel, SQL ,Trizetto Facets, MMIS

Responsibilities:

• Gathered and documented business requirements from SMEs, user groups and vendors via workshops, interviews and JAD sessions.
• Prepared a comprehensive Functional Requirements Document and Supplementary Specification Document nonfunctional from the gathered requirements.
• Involved in writing USE cases and prepared the Business Requirements Documents for various requirements collected from the business users. Used MS Visio and UML for generating class diagrams and activity diagrams.
• Worked in close collaboration with the Project Manager, Vendor team and business users to gather analyze and document the functional requirements for the project.
• Facilitated and managed meeting sessions with committee of SME's from various business areas including Benefits Administration, Health Claims Group, HIPAA Administration, Health Policy and Program Evaluation Team and Data Management Group.
• Created Functional specifications for the Provider tracks with their changed Reimbursement and Administration in the Medicare and Medicaid program. Worked on PCC and Referrals Benefit tiring.
• Gathered and documented requirements for CCS Benefit track for health insurance carriers.
• Participated in entering, tracking system defects in Rational Clear quest.
• Submitted change requests and worked with change request records in Clear quest.
• Involved in Configuration Management, Requirement management and analysis.
• Provide technical and procedural support for User Acceptance Testing UAT .
• Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management

Confidential

Business Analyst

Environment: Mercury Test Director 8.0, PVCS Tracker, Oracle 9i, Java/J2EE, RequisitePro, ClearCase, ClearQuest, MS Project.

Responsibilities:

• Helped create Level I and Level II specifications including VISIO data and program flow charts utilizing Gentran Translator's capabilities and limitations. These techno-commercial documents were presented to the state of New York for their approval for claims 837I/837P/837D , Service Review Request and Response or Prior Authorizations 278 , Eligibility Verifications 270/271 and Claim Status Request/Notification 276/277 . Outbound batch transactions included Claim Payment Advice 835 .
• Researched the then current application, various compliance issues, providing insights to the architecture group, Security group, and resource management group for effective budgeting, bridging with the Translator vendor's technical group and converting these semantics to the eMedNY application.
• Helped alleviate the problem of insufficient test data, inaccurate test files by creating large and complex, compliant and non-compliant test files with positive and negative test conditions. Helped achieve conformance by doing unit testing, system testing, regression testing, volume testing, end-to-end testing, user acceptance testing UAT , Trading Partner enablement by first promulgating test cases and test scenarios and creating a test result documentation methodology that supports a stringent pedantic testing but also eventually supports a realistic production environment.
• Create customized Implementation Guides using the SpecBuilder 5.1 module of EDIFECS software for 837 Professional, 837 Institutional, 837 Dental, 835 Remittance Advice, 276/277 Claim Status/Response transactions, 278 270/271 and all NCPDP transactions like B1, B2, B3, B4, E1, P1, P2, P3, P4.
• Involved in Validating the System in Accordance with 21CFR Part 11.
• Created use case narratives to record Subscription business rules.
• Analyzed the business rules for the international user subscription and impact of localization.
• Implemented SDLC, which included requirements specifications, design, analysis and testing. Followed RUP methodology with Agile/Extreme Programming and using Rational Test Suite for various phases of RUP.
• Provided technical Expertise on the use of Rational Clear Case and Requisite pro, which were used for Data archiving and Requirements Management.
• Defect Tracking with Clear Quest, Configuration Management with Clear Case.
• Involved in preparing test plan and test cases based of functional requirements using Rational Test Manager.
• Work experience in maintaining data marts dealing with ETL extraction, transformation, and load using Oracle and Informatica.
• Dealt with data mapping issues between various source systems and staging area and data-marts.
• Worked with Business users to come up with Reporting Requirements. Reports were developed in Cognos.
• 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.
• As member of system architecture team designed and reviewed user interface.
• Developed Business case and assessed the ROI.

Confidential

Business Analyst

Environment: Sybase, SQL 2005, Facets 4.41 4.51, Agile, IVSTech Data Toolset, DB2,NASCO, PeopleSoft, Pega System, MS Office Tools, MS Visio, SAS, Lotus Notes, Lotus Quickr, Citrix Program Neighborhood, IBM Process Modeler, Windows XP, UML, Mercury Quality Center MQC

Responsibilities:

• Primary responsibilities included Gap analysis, Data analysis, interpretation and leadership of resources to meet business needs providing effective technology solutions.
• Gathered requirements from the SMEs Subject Matter Expert , prepared BRD Business Requirement Documents using standard document templates, and constantly communicated risks/contingencies to project managers, consulting with technical development staff to clarify business requirements.
• Worked in Facets Reconfiguration Data Element Definition and Usage Working with values and completed configuring FACETS Applications like Related Entity, Parent Group, Group, Subgroup, and Member/Subscriber using IVSTech Data Toolset.
• Analyzed data and created reports using T-SQL queries for all issued Action Items.
• Developed Data Mapping and Crosswalk.
• Completed Data Mapping for Group and detail Product analysis and report writing.
• Participated in solving Billing issues from the FACETS Problem log for Trizettoteam and Billing Entities.
• Performed data validation, loading and unit testing.
• Participated in IBM Process Modeler WebSphere Business Modeler training and developed Business Process Model for different Business Processes followed by HealthNow including E2E End to End Member Enrollment.
• Designed Flow chart and process model for different department including business and HR.
• Extracting data from mainframe/DB2 using SQL data analysis and reporting for different department.
• Developed Business Process like setting up Group or Subgroup Billing Entity using Billing Profile and CHP enrollment in Visio.
• Documented and mapped the various CPT and ICD 9 codes with incoming claim messages. Analyzed the impact of changes to ICD 9 codes on various sub-systems.
• Involved in analyzing the components for claims adjudication in ITS.
• Involved in preparing use cases and designed/documented test cases corresponding to the various scenarios that can occur in the ITS systems involving blue card members.
• Provided an analytical assessment of current business functions and solicit input for system requirements including functional future state requirements.
• Collaborated with SBU's Strategic Business Units and Core operations to communicate progress, resolve issues, and develop partnerships.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Tracked and reported change, incident, and risk management standards, processes, and HealthNow policies.
• Implemented methodology to acquire business requirements from organizational Subject Matter Experts, developers and user interface designers.
• Facilitated FACETS requirements and Use Case sessions with SMEs.
• Conducted research, analyze data and develop/recommend business solutions.
• Exposed to extensive experience levels and overall knowledge in the suite of Facets Applications such as Accounting, Billing, Capitation/Risk, Membership, Provider, Eligibility, Group, Product, Enrollment, Provider, Claims, Correspondence and Letters, Facilities, Customer Service and Health Care Regulatory standards.
• Participated in HealthNow Products: Planning for Success program which included Traditional, PPO Preferred Provider Organization , EPO Exclusive Provider Organization , POS Point of Service and HMO Health Maintenance Organization .
• Participated in Life of a Claim training, detail Claim process tour included HIPAA compliance, electronic EDI 837, EDI 835, etc. and paper claim processing CMS 1500, UB04, ADA Claim form and Vision .
• Worked with Pega developer to document business rules and batch processing system for Claims processing and also participated in Pega's End-to-End Sales POC presentation Demo for SPM .
• Used Pega to configure Sales Process Manager Framework SPM to address the HealthNow's pain points and needs.
• Documented data source definition, source-to-target mapping, and logical structures for the data warehouse/data mart.
• 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.