SUMMARY:

Highly motivated and proactive professional with solid experience in HealthCare Domain and IT industries is seeking a position to utilize analytical, technical and strategic-thinking skills, and to make a positive contribution to the further success of the employer

Career Summary

• Highly motivated, versatile, and results-driven Business Analyst with over 4 years' experience in all phases of the Software Development Life Cycle SDLC .
• Professional 6 years' experience in Healthcare/pharmaceutical industry
• Specialized in Healthcare, Insurance, and Compliance, Document management.
• Solid understanding of Business Requirement gathering, Business Process flow/Modeling/Analysis
• Proficient in gathering business requirements from both formal and informal sessions through interviews, NetMeeting, questionnaire, video conferencing, JAD sessions and conference calls.
• Prepared Business Requirement Document BRD validated that all the requirements are adequately captured and obtained the Statement of Work SOW from the vendors.
• Expertise in facilitating JAD sessions with business users and development team to drive out detailed business requirements using various techniques from BABOK Business Analyst book of knowledge .
• Expertise in creating Use Case diagrams, Activity diagrams, Sequence diagrams, State diagrams based on UML Methodology and business process flow diagrams using MS Visio and other BPM tools.
• Exceptional Skills in writing Use Cases and Business Requirements using Requirements Management Tools: Rational Requisite Pro and BluePrint
• Strong Experience in Medicaid Claims Processing and Claims adjudication
• Familiar with HIPAA 5010 transaction requirements: 270/271, 276/277, 820, 834, especially in 835 and 837.
• Worked on healthcare standards such as HIPPA 4010, 5010, ICD-9, and ICD-10.
• Sound knowledge on HIPAA 4010A1 to 5010 versions and changes involved with all EDI transactions
• Excellent knowledge on ICD 10 codes, and their structural and functional differences with ICD 9 codes.
• Excellent understanding on HIPAA 5010 and ICD-10 conversion strategies and business impacts involved in implementation.
• Expertise in ICD-9 to ICD-10 Conversion an involved in the enterprise impact analysis.
• Worked on various Professional billing and Forms: CMS-1500 and UB-04
• Worked/knowledge on healthcare software such Medics, Raintree, FACETS
• Experience in assisting the Development team during construction periods and assisting the QA team in test case design as well as performing UAT and provide presentations to the business team.
• Using project management tools like MS-Excel and MS-Project for status reporting and planning.
• Excellent Client relationship management, analytical, problem solving, written and oral communication, and presentation skills.
• Ability to work independently or in a team/cross-functional teams, manage and prioritize multiple projects.
• Sound analytical and problem solving abilities

Technical SKILLS

• Primary Skills: Medicare, Medicaid, EDI, IVR, ICD-9, ICD-10, ANSI X12 transactions 4010 and 5010 , UML, RUP
• Tools: Blue Print, Rational Rose, Rational Requisite Pro
• Methodology: Waterfall, agile, RUP, UML, Business Modeling, Process Modeling and Data Modeling
• Office Tools: MS Suite of Tools MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook
• Operating Systems: Windows XP/Vista/2007
• Databases: MS Access, FACETS, MACESS, MADICS, RainTree

AREAS OF EXPERTISE

Agile/Waterfall Technical Writing Software Development Life Cycle SDLC Documentation Status and Progress Reporting Research and Analysis Time Management Communicative Skills Stakeholder and Vendor Relations Team Player Team Leadership and Supervision Business Development Process Improvement Problem Solving

Professional WORK EXPERIENCE

Business Analyst

Confidential Medicaid managed care leader, AmeriHealth Caritas provides responsible managed care solutions for underserved populations. These include Medicaid, Medicare, and CHIP plus pharmacy benefits management, behavioral health, and administrative services.

Projects with ACFC:

• Administrative Simplification by HHS provisions of the Affordable Care Act ACA of 2010
• Enterprise ICD-10 Implementation
• HIPAA 5010 Implementation and Paper Claim to HIPAA 5010 Conversion

Administration Simplification Initiative by HHS

Project Description: Confidential includes provisions for Administrative Simplification which has added to the Health Insurance Portability and Accountability Act of 1996 HIPAA several new, expanded, or revised provisions. The act requires the adoption of CAQH Phase III CORE operating rules for each HIPAA transaction, enumeration of a unique, standard Health Plan Identifier HPID , new standards for electronic funds transfer and electronic health care claims attachments, health plans to certify compliance with the standards and operating rules, penalties for health plans that fail to comply or to certify their compliance with applicable standards and operating rules, as well as new standards. This project was to verify ACFC's compliance to CAQH Phase III CORE requirements for applicable HIPAA 5010 standards for 835 and EFT transactions.

Responsibilities

• Analysis on existing HIPAA 5010 Standards, 835-ERA and EFT Transactions and provided the inputs to Executive Management Team on how ACFC can be certified as meeting the CAQH CORE III operating rule requirements.
• Conducted JAD sessions with all the impacted areas in gathering requirements for CORE III operating rules.
• Delivered Gap Analysis for the HIPAA transactions to comply with the Administrative Simplification Operating rules.
• Worked with the business team to collect the business requirements, Conducted interviews, and analyzed the requirements in form of walk-throughs and documented them into the BluePrint requirements management tool.
• Worked with different IT Teams, Business groups, and clearinghouse Emdeon and HDX groups to understand and determine the Impacts of the ERA and EFT Process.
• Participated in the discussion of adding logic and physical design sessions when developed design documents for the 'Trace Number' on both ERA and EFT transaction
• Designed new 835 ERA process flows for the existing state as well as future state.
• Established business analysis methodology after assessing the corporate and HIPAA 835 compliance procedures
• Conducted and lead status report meetings with the business and the IT team on a weekly basis.
• Co-authored Functional Requirements Specification FRS , System Use Cases, with the IT project group members.
• Identified all necessary Business and System Use Cases from requirements, created UML diagrams including Use Case Diagrams, Activity Diagrams, and Sequence Diagrams using Microsoft Visio.
• Understood the Business Logic, User Requirements and assisted QA with test-objectives to develop Test plans, Test cases, Use Case Scenarios.
• Assisted in developing test scenarios, test scripts and test data to support unit and system integration testing.
• Involved in comprehensive testing of the system to check it satisfies functional specifications.
• Identified the deliverables for the SDLC for a successful project execution and requirements analysis.
• Created and maintained the Requirement Traceability Matrix RTM between the BRS, FRS, and Test Document.
• Manage Scope and change throughout the life cycle of the product.
• Maintained all the requirements, Business Process Flows and Use Cases in the BluePrint requirements management repository.
• Modified Existing policies and procedures for the current EFT Process to meet the CORE III Compliance.

Environment: MS Project, MS Visio, RUP, Blueprint, EFT and EDI ANSI X12/HIPAA transaction 835-ERA, FACETS, WTX

Business Analyst

Confidential refers to a federal mandate issued by the US Department of Health and Human Services HHS , Centers for Medicare and Medicaid Services CMS . All Health Insurance Portability and Accountability Act HIPAA covered entities must transition to the Clinical Modification ICD-10 Clinical Modification CM for diagnosis coding and ICD-10 Procedure Coding System PCS for procedure coding. The original implementation date was October 1, 2014.

Responsibilities:

• Conducted impact assessment sessions for Claims Processing rules to identify impacted functional area by ICD- 10 implementation project.
• Identified business rules supporting the ICD codes related to processing of claims, remediation of other business processes that may use ICD codes, including group and member enrollment, provider pricing configuration, product configuration, and medical policy configuration must be in place.
• Conducted JAD sessions with Project Team, Sponsor, SMEs, and developers to build high level project scope.
• Conducted JAD sessions with impacted functional areas to understand the Business Requirements and Rules to ensure that claims can be received, loaded and processed with both ICD-9 and ICD-10 codes in FACETS claims processing system for business to run as usual as of the compliance date, 10/1/2014.
• Conducted interviews sessions along with the product team to capture ICD-9 to ICD-10 Code conversion rules.
• Involved in defining ICD-9 to ICD-10 mapping process using GEMs General Equivalency Mapping crosswalk file.
• Participated in Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10.
• Worked with Vendors and Sub Contractors iHealth, McKesson and HMS to validate the claims adjudication work processes that use ICD-9 codes.
• Identified and documented ICD-10 impacted Encounters Requirements for state reporting.
• Created the Process flow for inbound and outbound Encounters processes to support the storage, transmission of ICD-10 codes, and encounter files that use proprietary formats to be able to support the use of ICD-10 codes.
• Conducted Business Requirements walkthrough with the business owners as well as the Technical Stakeholders.
• Involved with UAT team to Plan for the project testing and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT test plan.
• Prepared Traceability Matrix to establish forward and backward traceability between scope, requirements, test cases, user acceptance test cases.

Environment: 837, 5010, ICD-9, ICD10, FACETS, EXP Macess, BluePrint, Windows XP, HP Quality Center, Facets

Business Analyst

Confidential standards. All the Healthcare Entities must be ready to submit claims electronically using HIPAA Version 5010. The new version supports the ability to identify the ICD-9 and ICD-10 codes within the schema. The EDI 5010 Project was initiated to perform Gap Analysis and document the necessary changes and implement the process for all X12 transactions received via EDI.

Responsibilities:

• Gathered and understood documents related to 5010 transaction sets
• Conducted JAD sessions to create gap document supporting segment level and loop level changes between 4010 and 5010 version
• Created a PowerPoint presentation for stakeholders to share the changes between two versions.
• Conducted sessions in form of session called workgroup solution to resolve conflicts pertaining to both the business and software FACETS.
• Worked with cross functional Team's management to create and communicate critical information to the user community via email and discussion boards.
• Gathered business requirements from stakeholders, executive sponsors and business users to draft the Business Requirement Specification BRS .
• Co-authored Functional Requirements Specification FRS , Use Case Specifications, Systems Requirement Specification SRS and Change Request along with the Business Group and the IT project group members.
• Understood the Business Logic, User Requirements and Test Objectives to develop Test plans, Test cases, Use Case Scenarios.
• Co-authored Test Cases for 837, 835, 270/271, 276/277, 820, and 834 Transactions.
• Worked with Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA.
• Provide solutions on Claim Processing Application for the implementation of HIPAA mainly used for Claims Adjudication Process.
• Created use cases after accessing the scope and status of the project and understanding the business processes from USER perspective
• Created Activity Diagrams and Data Flow Diagrams in MS Visio to illustrate both the Existing 4010 Process Flow vs. the Proposed 5010 Process Flow.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams and UML
• Maintained quality procedures and ensuring that appropriate documentation is in place.
• Providing full time business support to development and testing team for their queries
• Prepared high level test scenarios on X12 5010 based business requirements to assist the QA Team.
• Validated test data prepared by the test team on 5010 EDI transactions and provided necessary inputs so that all the changes were appropriately addressed in the testing.
• Coordinated with end-user during the UAT testing over several cycles and oversaw sign-off.
• Explore different phases in the SDLC lifecycle and then created the system in a way that the riskier claims could be easily identified and monitored.
• Supporting the Business Users after go live.

Environment: Oracle, UML, BluePrint. Microsoft Office Suite Excel, Word, PowerPoint , Visio, Project, Windows XP/Vista

Lead/Analyst/Business Analyst

Confidential from Medicaid Providers, billing agencies and Medicare intermediaries. I was involved the entire process of implementing Raintree at Fox Rehabilitation and to making sure that the 837 Claims and 835 Remittance Advice transactions passes the HIPAA compliant by directing and working with the development contractors and Client site.

Responsibilities:

• Coordinating all aspects of projects such as initiation, planning, scheduling, task assignment and tracking, status reporting and risk management.
• Facilitated team meetings to coordinate activities for project schedules to presented deliverables to the management.
• Facilitated JAD sessions, conducted interviews, Q A sessions with business users to solicit business
• Analyzed, collected and prepared user requirements, definitions, scope and expectations
• Managed requirements to minimize scope issues. Understand all system requirements and provide feedback, collected requirements from customers, users and prioritized them.
• Wrote clear, concise detailed system requirements specification SRS documents and user documentation in accordance with the guidelines and standards of a level where developers can interpret, design and develop the application with minimum guidance.
• Interacted closely with the Subject matter experts SME for the functional requirements gathering relative to proposed functionality and created Functional and Non-functional requirements.
• Worked on specific Modules: Billing and Collection, Reports and Forms
• Designed and developed Use Cases, UML Diagrams for detailed process and flows.
• Worked closely with the development team to clarify and understand functionality, resolve issues and provided feedback from the UML diagrams.
• Involved in the creation and maintenance of the Workflow plans and artifacts.
• Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level.
• Monitors, and tracks system performance and problem logs. Evaluates and monitors coded data elements.
• Identify business process and/or technology problems and issues participate
• Performs System testing, User Acceptance Testing, Best Practices testing by executing scripts employing analytical and statistical skills.

Environment: UML, Rational Requisite Pro, Use Case Analysis, MS Visio, MS Office

Analyst, Strategic Initiatives

Confidential

Responsibilities:

• Billing and Submit insurance claims daily for patients with HIPPA requirement.

• Maintain all appropriate patient records in PDX software in order to facilitate proper billing.
• Engage in dialog with Insurance companies as required to obtain and enter accurate benefit information to positively impact insurance processing and minimize rejection.
• Provide solution to the vendors of the company reimbursement aspect in regard to claims processing.
• Obtain clinical information needed for order processing and reimbursement.
• Analyze and track the usage of federally controlled drugs within the division.
• Conduct reviews to identify trends that may be indicators of system set up problems, claims analyst procedural errors, and/or inaccurate billing and provide solution to the client.
• Create claim payment report and Analyze the result by establishing processes for and actively pursuing the recovery of overpaid claim amounts.
• Research rejected/denied claims form CMS and track these claims in MS Access Database.
• Routinely review credit balance accounts pursue recovery on accounts that have no recent claim activity.
• Conduct root cause analysis on bulk provider claim issues to identify cause of billing/payment issues. Make recommendations for corrections.
• Keep up-to-date with drug recalls in the market by FDA.
• Support staff by providing training and educating in medical areas and most updated healthcare changes, issues, and updates.
• Conduct study or survey on need or problem to obtain data required for solution.
• Responsible for formulating and implementing innovative strategies of the division.