- With over 7 years of IT and Management experience in Software Development Life Cycle SDLC and Project Life Cycle working as Business System Analyst mainly in Healthcare, Insurance and Financial Industries.
- Worked with ICD 9 to ICD 10 upgrade, 4010 to 5010 conversion and worked on HIPAA X12 EDI transaction codes such as 270/271 inquiry/response health care benefits , 276/277 Claim status , 834 Benefit enrollment , 835 Payment/remittance advice/ Explanation of benefits , 837 Health care claim
- Experience in the Healthcare Industry. Sound domain knowledge on the Healthcare practice management, Physician patient web portals, EHR, RCM /Claim processing, e-Prescription process, and Healthcare Insurance payer process
- Experience in conducting Joint Application Development JAD sessions for requirements gathering, analysis and design, and Rapid Application Development RAD sessions to congregate early toward a design acceptable to the customer and feasible for the developers.
- Proven track record with handling Change Requests by the Clients.
- Strong knowledge of HL7, HIX Health Insurance Exchange , EMR/EHR, Health Care Reform and Patient Protection and Affordable Care Act PPACA and Facets.
- Extensive knowledge of Healthcare Insurance including Medicaid. Medicaid Information Technology MITA , Medicare Part A, B, C, D , Procedural and Diagnostic codes, Claims Process and Medicaid Management Information Systems MMIS
- Managed complex business initiatives to balance requirements for functionality, efficiency and quality.
- Developed business requirements by analyzing the As-Is system and designing the To-Be system to stream-line business strategies. Suggested improvements to business processes through better use of existing technology.
- Exceptional Documentation Skills for writing Use Cases and Functional Requirement Documents as well as for creating Use Case diagrams, Activity diagrams, Data Flow Diagrams DFD , Sequence diagrams, State diagrams, Diagrams based on UML Methodology and business process flow diagrams using MS Visio/Enterprise Architect/Rational Rose.
- Experienced in System Development Life Cycle SDLC , involved in different phases of development from Information analysis, Data modeling.
- Strong expertise in employing Rational Unified Process RUP methodology throughout the SDLC process
- Conducted JAD Sessions, brainstorming sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
- Experienced in performing Business Process Reengineering/Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
- Coordinated with the testing team during the formulation of Test Plan and Test Cases for Functional, System, Integration, UAT and Regression Testing based on the Design Document and User Requirement Document for the Functional and Performance Testing.
- Strengths include quick learner, problem-solving capability, conflict solving, time management skills and ability to lead the teams.
Business Skills: Business Process Analysis Design, Requirement Gathering, Use Case Modeling, JAD/JRP Sessions, Gap Analysis, Impact analysis, Data Mapping and Data Modeling
OOAD and DESIGN: Rational Rose, UML with Class, Sequence and Use case diagrams, Visio and Enterprise Architect
Operating Systems: WINDOWS 2000/NT 4.0/XP
Languages: SQL, HTML, XML
Packages: Rational Rose, Requisite Pro, Clear Quest, I log J-Rules
Databases: MS Access, MS SQL Server
Office tools: MS Office 2003/2007 Word, Excel, Power Point, Outlook , MS Visio, Lotus Notes, Microsoft Share Point, Optimal Trace, Caliber RM and MS Project.
Business/ Systems Analyst
- Worked closely with State Technical Business SME' for gathering Technical and Business requirements definition and activities as described in the Request for Proposal RFP
- Actively worked with both internal and State team to leverage existing materials such as the latest Centers for Medicare Medicaid Services CMS certification/checklist requirements for new MMIS in order to establish baseline system requirements
- Involved in facilitating strategic visioning activities, team meetings with the State and key stakeholders
- Coordinate with current MMIS vendors/FAS in researching activities including, but not limited to, allowing the MMIS vendors to provide relevant potential process and technology solutions for the State of Vermont and key stakeholders to consider.
- Interact with current MMIS vendors and collected necessary information regarding their creative and industry best practice solutions
- Developed Agency Enterprise Architecture Analysis - Vision Documents, Business and Functional Requirements, Technical Requirements and General System Design documents
- Worked with internal team for developing Business, Information and Technical Architecture sections and further validate them with State SME's for accuracy
- Involved in developing Business Functional and Technical Requirements for Fiscal Agent Services and MMIS Procurement
- Mapping of Vermont's identified Business and Technical processes to MITA business areas and business processes that are specific to State Divisions/Agencies and Departments.
- Schedule meetings with SMEs to review MITA results for both Technical and Business areas
- Involved in preparing Technical and Business process templates and compile with received agency SME's input and further revalidate them with agency stakeholders prior to finalizing the documents
- Generate To-be project road map that describes and prioritizes tasks and provides a high-level implementation schedule.
- Worked closely with agency SME's for capturing the As-Is , Evolving and To-Be 5-10 years out picture of the Vermont Medicaid Enterprise Business and Technical Architecture information
- Gap Assessment using the SS-A as the As-Is inventory and identifying the gaps between the current Vermont Medicaid processes, systems and the MITA Framework 2.1.
- Involved in assessing current As Is and To Be against MITA Maturity Model
- Assist in the development of an Implementation Advanced Planning Document IAPD
- Worked with internal team to design, create and maintain SharePoint portal
Environment: VISIO 2007, MS Project 2007, MS Office, Excel, Power Point, MS Access, SharePoint and RFP evaluation tools internal
- Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers and Clearing houses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the HIPAA 5010 compliance requirements.
- Produced a full gap analysis for transaction sets 835 and 837 I/P against the documented application on HIPAA 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliance.
- Designed and developed Business Rules document about the Claim Component and HIPAA.
- Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non functional requirements.
- Propose different strategies to implement HIPAA 4010 in the new MMIS system.
- Conducting meeting with the client on a daily basis and reporting on daily progress
- Specifications, Documentation and Construction of systems heavily relied on UML modeling.
- Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions.
- Performed the Gap analysis on the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
- Designed robust HIPAA 5010 testing and HIPAA 4010 regression SIT and UAT Testing Scripts for the 5010 Project. Scripts were written on an application level and subset by payer resulting in over 600 combined scripts with a maximum of 70 testing scripts steps per script.
- Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis expected results for 5010 compliance.
- Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
- Took action in the process flow to prevent rejected claims from falling into limbo . Mitigated claim denial increase through a complete analysis of the application Claims Scrubber to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.
- Validated the receiving A/R applications up to 12 recipient applications received the correct split file and the application was able to correctly post the 5010 compliant 835 file.
- Tracked all required resolutions required that were identified as needed from Vendors or Payers based on testing results.
- Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.
Environment: RUP, Rational RequisitePro, Rational Soda, Rational Rose, Rational Clear Case, Rational Clear quest, Java, MS VISIO, MS Project, Oracle, HTML, WINDOWS
Business / Systems Analyst
- Designed High level design, for New process, integrating with legacy and Facets
- Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
- Planned and documented procedures for data processing and prepared data flow diagrams for the application.
- Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
- Defined Functional Test Cases, documented, Executed test script in Facets system.
- Followed the standards of PMO which included getting approvals for SOX Compliance at various Gates.
- Prepared Functional Design Specifications employing Use case scenarios, sequence diagrams, ERD's, DFD's and class diagrams
- Gathered high level requirements and developed scope of the project for the implementation of Microsoft Office Share Point 2007.
- Claims testing of NASCO contracts via NPS system for different test claim scenarios and projects. Verify test cases for healthcare reform, changes in benefits are processing as expected.
- Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
- Recommended changes for system design, policies and workflow affecting Medicare Medicaid Claims processing system in compliance with current government process like HIPAA and EDI.
- Monitoring of critical COTS services
- Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
- Impact analysis and feasibility study of system to incorporate new functionalities in ETL
- Report daily to the COTS Maintenance Manager to assist in any maintenance warranty issues.
- Actively involved in changing and upgrading existing system logic within the NASCO
- Processing System NPS for all Blue Cross Blue Shield Control Plans.
- Worked with HIPAA 270,271,835,837 transactions. Performed validation of 270,271,835 and 837 Professional and Institutional format files according to EDIFECS engine.
- Used SSIS to create ETL packages .dtsx files to validate, extract, transform and load data to data warehouse databases
- Business Requirements, Systems Requirements, Test Criteria, and Implementation to have the outputs of project dealt with the automation of correspondence directed to Insurance policy owners
- Provide technical expertise as an early engagement to different modules and enhancements to access impacts and define scope.
- Generated database SQL scripts and deployed databases including installation and configuration.
- Formulated logical statements of business requirements researched and evaluated alternative solutions and recommend the most efficient solution for system design.
- Review requirements and understand technical recommendations and constraints, and develop comprehensive and accurate functional specifications Data Mapping, and process flows.
- Work with Compliance and Regulatory operations to follow and monitor different IT process bound by CMS Regulations.
Environment: Windows XP, Business Objects, MS Excel, EDI, Word, Visio, Rational Clear Quest, Rational Clear Case, BPM, ETL, SQL Server SSAS SSRS SSIS, Facets, power point, COTS, SQL, NASCO, DB2, SAS database.
- Studied business requirements and conduced User Interviews to identify and document the data discrepancies and their sources as related to Government Contract Compliance GCC , Government Disclosures, Government Pricing, Customers, Products, Product pricing.
- Responsible for developing applications for physicians' electronic billing and scheduling, and electronic medical records EMR .
- Successfully handled the testing of health care products like Epic Systems and EHR Electronic Health Record .
- Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
- Maintained existing Benefits configuration in AMISYS
- Supporting client's HEDIS Processes and Reporting needs, and helping them to reach new levels of performance.
- Worked on requirements and completely developed the new process for HEDIS data processing.
- After Executive confirmation did Gap analysis to assess needs that could not be met by core EHR.
- Worked on Electronic health record system as a CRM web based application.
- Developed extensive experience in eligibility and benefits calculation for state, federal and local services such as Medicare and Medicaid.
- Performed felid-by-field mapping of interface between parent EMR system and downstream system.
- Worked on Claims Processing per Medicaid Management Information Systems MMIS 42 CFR 433.
- Created Business Requirement Document BRD , Functional Requirement Specification FRS document, User Requirement Specification URS and Change Request CR document for system application development.
- Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
- Collaborated in building a business analysis process model using Rational Rose, RequisitePro, and Visio.
- Responsibility included modifications to a customer's mainframe system to support new product features or regulatory requirements and, in some cases, involved a system upgrade.
- Performed pricing keywords and benefits analysis on claims pending for missing configuration scenarios in order to make corrections to processing logic in AMISYS.
- Converted Business Requirements to the Functional Specification and Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
- Use Cases and other Process Flow Models were designed using Visio and Rational Rose.
- Helped in developing QA Test plans for Systems integration and System Testing. Performed Black Box Testing. Performed GUI testing and user acceptance testing UAT .
- Identify Member, Provider, Coverage, Medicare, and Medicaid
- Worked on modules related to Providers, Contract Claims and worked with Claims, Provider attributes, enabling EOB Remit rules associated with Provider configuration process in QNXT.
- Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
- Established a RUP Rational Unified Process centric business analysis methodology.
- Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
- Created Use Case Diagrams, Activity Diagrams, Sequence Diagrams and ER Diagrams in MS Project.
- Automated confidence tests that run on new builds on regular basis.
- Managing overall testing process and project to production change management life-cycle.
- Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
Environment: Windows 98/2000, Window2003, Window NT, Linux, Mainframe, Solaris IBM Web sphere, Load Runner 8.2, Oracle 8i/9i/10g, SQL Server 2000, DB2, Toad, MS-Project 2000/2003.