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Sr. Business Analyst Resume Profile

Tampa, FL

Summary:

Please use this table to list the skills noted in the Required/Desired section of the requirement. In addition, please respond with the years of experience for each skill and the last time each skill was used. Add or delete rows as necessary.

Confidential

Sr. Business Analyst

Project Description:

The core business of Confidential is to provide managed care services for government-sponsored health care programs with a focus primarily on Confidential. As a part of the claims Process Improvement, WellCare is trying to streamline its business process by eliminating the bottlenecks, identifying and replacing functionalities of the external systems like Legacy/AdminisTEP with the internal systems like HIP and their functionalities.

Responsibilities:

  • Helped to identify the whole claims process flow and characterized in the form of a Claims Process Flow diagram identifying each and every touch points or events that the claim goes through before getting adjudicated.
  • Worked extensively with ASC X12N 837I, ASC X12N 837P and ASC X12N 837D and as a part of the Synthetic Image mapping, Mapped X12 to 837 for Institutional and Professional claims.
  • Mapped the various loops, segments and elements as a part of the X12 mapping for the member, provider and vendor pick.
  • Identified the current processes in Legacy/AdminisTEP member pick, provider pick, vendor pick the logics involved and documented it based on the business's future requirements.
  • Conducted Gap Analysis on the AS-IS and TO-BE business processes and technology and identified potential pitfalls, risks, and issues.
  • Conducted JAD sessions with the Business Subject Matter Experts and developers to gather, analyze, and document the business system requirements
  • Worked on projects with different methodologies like Waterfall, Agile and RUP.
  • Worked on creating the claims Management interface that combined Reports, Claims Reconciliation, Historical claims and claims configuration UI
  • Created Business Requirement Document BRD and Functional Requirement Documents FRD and Crosswalks for COB and NDC
  • Identified and documented the Claims Rerun Process to rerun claims that have been incorrectly denied/ rejected or if the claim was paid to an incorrect member, provider or vendor, and the system have since been changed.
  • Documented the Historical claims search FSD by detailing the complete lifecycle history of the claim.
  • Validated X12 files against database using SQL queries in SQL Developer and TOAD.
  • Worked on PCR's as a part of the project change request for Synthetic Images ,Hawaii and Kentucky COBA
  • Collaborated with WellCare business users in identifying, defining, and documenting process improvement options and alternatives, as directed by business needs.

Environment: AdminisTEP, Transaction Manager, Microsoft Visual Studio ,MS office tools, MS Visio, TOAD, SQL Developer, Mercury Quality Center.

Confidential

Business Analyst

Project Description:

Participated in company-wide design, development, testing, and implementation transition from a legacy system to TriZetto's Facets enterprise solution. Adhered to strict compliance, policies/regulations configured Facets modules such as Claims, Membership and Benefit. Part of the project was to migrate all application functionality and convert data from a mainframe-based system to an open systems environment. I was assigned to work on code set rule and do Up-gradation from HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM Clinical modification to ICD-10-CM/PCS Clinical modification/procedure coding system simultaneously.

Responsibilities:

  • Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus.
  • Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
  • Developed Data Mapping and Crosswalk documents.
  • Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
  • Worked on requirements of the 835 HIPAA projects, 276/277, 278, 837, and HIPAA EDI Transactions across enterprise.
  • Initiated with a comparison report of migration of 4010 to 5010. 270 Eligibility, Coverage or Benefit Inquiry V4010X092A1 vs. 270 Eligibility, Coverage or Benefit Inquiry V5010X279 , 278 Prior Authorizations.
  • Tested the ANSI X12 Version 4010 / EDI transactions HIPAA like 270, 271, 276, 277, 278 837P, 837I, 837D, 835 remittances
  • Used General equivalence Mappings GEM to convert ICD 9 to ICD 10.
  • Worked on the existing mainframe system to understand the code written in COBOL, documented the system requirements from the COBOL code and came up with Use Cases from the analysis.
  • Wrote Test scenarios and test cases for testing the migration of EDI 4010 to 5010 and the processing of member enrollment and benefits, batch jobs corresponding to the claims 837 and real time transactions like 270/271/276/277.
  • Worked with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using General equivalence Mappings GEM .
  • Performed Gap Analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
  • Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems.
  • Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction 270/271 , Claims 837 , Claim Status Request and Response 276/277 , Remittance 835 .
  • Performed Migration and Validation per SDLC standards. Interacted with the Test Team and reviewed Test Plans and Cases.
  • Assisted in Regression Test, System Test, and UAT.
  • Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.

Environment: Sybase, SQL 2005, FACETS 4.41 4.51, Agile, DB2, .NET, MS Office Tools, MS Visio, SAS, Lotus Quicker, IBM Process Modeler, Windows XP, UML, Mercury Quality Center

Confidential

Business System Analyst

Project Description:

As a part of the project I worked on MMIS Claims processing module of the Confidential. The claims processing module involved Receipt and Verification of Claim Forms 837 and Claims Attachments 275 , Claims Enquiry and Response 276/277 , Adjudication, Healthcare Claim Payment/Advice 835 as per HIPAA guidelines. Also upgraded the transactions from HIPAA 4010 to 5010 and ICD 9 to ICD 10.

Responsibilities:

  • Elicited requirements from Subject Matter Experts and documented them per the needs and requirements of the project.
  • Analyzed the functional details of various modules in mainframe and did the GAP Analysis with the new system.
  • Prepared the Business requirement Document BRD and functional requirement document FRD for the enhancement of the existing services
  • Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
  • Worked on projects with different methodologies like Waterfall, Agile and RUP.
  • Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts
  • Created workflow diagrams, UML diagrams, process models, activity diagrams, use cases, swim lanes, for incorporating design changes in the order creation/ management system
  • Performed the forward and reverse data mapping between the fields in mainframe and FACETS.
  • Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
  • Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance.
  • Involved in claim adjudication process of facets application.
  • Prepared Test Data for the UAT as per the specifications of the FRD.
  • Worked on the EDI 834-file load to Facets through MMS Membership maintenance sub-system
  • Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions and also for ICD9 to ICD10
  • Utilized Agile Methodology to configure and develop process, standards and procedures
  • Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using GEM
  • Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches member load, Billing, Provider, etc .
  • Re-engineering and capturing of transactions with legacy systems Enrollment -834, Eligibility Transaction 270/271 , Claims 837 , Claim Status Request and Response 276/277 , Remittance 835 .
  • Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system Amysis to FACETS Client Server based system .
  • Performed Migration and Validation as per the SDLC standards.
  • Developed logical physical modeling as per business requirements.
  • Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize FACETS features not provided by the legacy systems.
  • Prepared Test cases. Conducted Integration tests and User Acceptance Tests.

Environment: Facets 4.51, Facets interfaces IFOX , Facets extensions, Agile, Requisite Pro, SQL, Share point, MS Access, MS Visio, MS office, MS word, MS excel Clear Case, Clear Quest, Quality Center, Oracle 9i, Data Warehousing, Java, Informatica 7.1, Cognos 8.4, MS Active Directory, LDAP

Confidential

Business Analyst

Project Description:

The Company had developed an application for Managing and processing Claims - Claims Management and Reconciliation CMR . Patient's information, history about disease and medication is collected and stored in the CMR Health Information Management/Enterprise Document Management System. I worked on enhancements and fixes to the Claim Engine with the various Business Owners.

Responsibilities:

  • Gathered Requirements from various Business Areas like Claims, Provider Relations, Enrollment, Finance and Benefits Administration for their updates to the Claim Processing Engine.
  • Delivered platform related specifications such as security, performance, and capacity, Standard code sets such as ICD-9, HIPAA EDI, CPT, National Provider Identifier, DRG etc.
  • Responsible for writing Functional Requirement Specifications FRS and User Requirement Specification URS .
  • Analyzed Business Requirements and developed Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams Activity Diagrams and State Chart Diagrams using Microsoft Visio and Rational Rose according to UML methodology thereby defining the Data Process Models.
  • Created activity report, logical components and deployment views to extract business process flows and workflows involved in the project.
  • Checked the data flow through the front end to backend and used SQL queries to extract the data from the database.
  • Performed enhancements on member eligibility and mass plan change, debit card authorizations for multiple subscriber and members and debit card authorization by running batches.
  • Monitored Change Requests and documented requirements, integrating them with Use Cases.
  • Assisted in Regression Test, System Test, and UAT.
  • Developed and Implemented Test Strategies using the Test Director.
  • Assisted QA team in testing phase by creating Test Plans and Test Cases documents.
  • Defect Tracking and Bug Reporting was performed using Test Director.
  • Followed the RUP methodology for the entire Software Development Cycles.
  • Developed the Requirements Traceability Matrix, prioritized and determined Impact of all applications.
  • Conducted JRP sessions and JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications.
  • Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions the performance of the application from various dimensions.
  • Identified all applications and interviewed the application owners to recommend the process improvements.

Environment: Oracle 8i, SQL, PL/SQL, ASP.NET, Rational Requisite Pro, Microsoft Visio, HTML, MS Office Tools, UML, Windows XP, MS Project 2003, Sharepoint, Clarity.

Confidential

Business Analyst

Project Description:

The Project was to upgrade the existing EOB explanation of benefits system to provide online EOB support to Medicare Part D members.

Responsibilities:

  • Understanding business requirements for Medicare Part D file required for CMS Risk Management, RAPS and suspect management .
  • Defined Business Processes that aligned with company goals and existing HIPAA regulations to communicate with CMS programmatically from Amisys system.
  • Created Project Charter to clearly define the project scope and objectives to the stakeholders.
  • Responsibilities spanned through all phase of the project life cycle from inception through post-implementation
  • Conducted one-on-one interviews and group meetings with the Subject Matter Experts SME's to gather the business requirements.
  • Created Entity Relationship diagram ERD and process flows using UML and Microsoft Visio to clearly communicate the business requirements.
  • Translated the business needs, wants and objectives on how to respond to coverage inquiries from both internal and external sources into requirements. Organized benefits structure to ensure accurate claims processing.
  • Created Business Requirement Document BRD and Functional Requirements Specification FRD using RequisitePro.
  • Developed the testing plans for all benefit structure. Organize and develop test plans for system upgrades
  • Prepared Test Data for the UAT as per the specifications of the FRD.
  • Developed Requirements Traceability Matrix RTM to track requirements against test cases during the QA Phase.
  • Facilitated formal defect review meetings with project teams and developers to report, demonstrate, prioritized and suggest resolution of issues discovered during testing.
  • Worked on projects with different methodologies like Waterfall, Agile and RUP.
  • Performed risk analysis of the requirements to identify key business areas for the project.
  • Played a key role in the planning, testing, and implementation of system enhancements and conversions. Trained non-technical Business Analyst in presentation, process analysis, and data modeling.

Environment: MS Office Tools, Access ,Windows XP, Oracle, SQL, Rational Clear Quest, Rational Clear Case, ERWIN, Requisite pro, Microsoft Visio, COBOL, C , Nasco, Amisys, Business Objects.

Confidential

Business Analyst

Project Description:

Confidential is a major banking and financial service company based in Confidential banking and bill pay for Confidential is a full featured website. The project encompassed data warehousing, online retail banking services wherein the users can view their account balances, transfer funds to different accounts, manage payments to other Financial Institutions by quick pay or recurring payments, view the most recent transactions, check credit risk report Confidential send and receive messages, loan transactions, online bill payment, change user information involved in credit cards and Back Office System.

Responsibilities:

  • Interacted effectively with business, technical staff and SMEs of the various applications to gain an understanding of the business process flow and available functionality of the individual applications and subsequently document support requirements clarifications.
  • Facilitated JAD sessions to collect requirements from system users and prepared business requirement that provided appropriate scope of work for technical team to develop prototype and overall system.
  • Identified processes for developing and documenting detailed business requirements including process, data flow analysis and modeling.
  • Created Use-Cases, BPM, and Requirement documents to document the Business needs.
  • Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts and other potential users of the application.
  • Conducted Use-Case reviews and identified Gaps, leading to improvements/enhancements in the same.
  • Created and maintained the Requirements Traceability Matrix RTM .
  • Worked with the Project Manager on various Project Management activities such as keeping track of the Project Status, Deadlines, Environment Request, and Compliance Issues.
  • Assisted the testing team with various testing like Unit testing, black box testing, SIT
  • Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
  • Responsible for building training materials to train team members with Business process.
  • Tracked issues that were detected and updated the status of existing issues based on the daily meetings with the off-shore team.
  • Followed the Agile methodology during the entire SDLC.

Environment: Windows XP, MS Visio 2003, MS Word 2003, MS Excel 2003, Mercury Quality Center, Autosys, XML, Java, Teamtrack.

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