To take a challenging role on business operations as Business Analyst and give an efficient and effective solution that would help the organization to achieve the best solution in business which would increase its productivity in market
- Healthcare Business Analyst with 6 years of experience in the HealthCare, Insurance Industry.
- Knowledge and expertise in working with Claims, Provider Relations, Enrollment, Benefits Administration, and Vendor Relations' Business Areas
- Vendor Management Worked as a facilitator for Testing Efforts and New Requirements between the Healthcare Company and its various Vendors.
- Worked in projects involving Benefit Base Plan changes and Configuration changes to ensure the accurate processing of claims. Determined dependencies between enrollment and benefits processes and ensured each Business Areas delivered their tasks on the projected target dates.
- Experience in Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10 Conversion for CM Diagnosis Codes and PCS Procedure Codes .
- Expertise in EDI HIPAA 4010 - 5010 Project to convert EDI X12 Healthcare 4010 transactions into 5010 Complaint transactions.
- Good understanding of Health Care Industry claims management process, Medicaid and Medicare Services and insurance sector.
- Implemented various HIPAA codes 270 and 276 used for Billing and Eligibility purposes of patient records.
- Expertise in all the phases of the Software Development Life Cycle SDLC , Agile Development and RUP methodology. mm
- Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and Rational Rose using UML concepts.
- Expertise in documenting the Business Requirements Document BRD , generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
- Eligibility File and Membership File Ensured accurate transmission of the eligibility file and membership file to Vendors and Delegates as a result of the annual Benefit Changes.
- Expert in building test plans and test cases and navigating through the test lab.
- Defect Management Fully involved in the process of defect identification and resolution using Test Director.
- Project Methodologies: Rational Unified Process RUP , UML, Agile, SDLC
- Business Modeling Tools: Rational Rose, MS Visio
- Requirement Management Tools: Rational RequisitePro, Informatica
- Defect Tracking Tools: Rational Clear Quest, Quality Center, Test Director
- Operating Systems: Windows NT/XP/2000, UNIX
- RDBMS: MS Access, Oracle, SQL Server, TOAD
- Quality Assurance Tools: Mercury Quality Test Pro. LOAD Runner, WinRunner
- Design Tool: Microsoft Visio, MS Excel
- Regulatory Knowledge: HIPPA, SOX
- Other tools: XDE/Websphere, COGNOS
Confidential interChange Enhancements. The purpose of the business transformation is to create a smooth transition from the current 'AS-is business environment to a new, more effective 'To Be' business environment that successfully incorporates MITS, and embraces and utilizes the Medicaid information Technology Architecture MITA . The projects were involved in upgrading the data requirements of the Medicaid Statistical Information System MSIS to Transformed MSIS T-MSIS to better track the performance and costs of the Medicaid Program. Enhancing the Recovery Audit Contractor Detail Underpayment Report FIN-RC01-M by adding a summary and total of recoveries by federal year at the bottom of the report. Updating 835 processing within MITS to better support the Affordable Care Act ACA section 104 rule 360 in the area of uniform use of Claim Adjustment Reason Codes CARCs and Remittance Advice Remark Codes RARCs and rebranding MITS generated letters and companion guides with new logo and agency name for the Ohio Department of Medicaid.
- Used ITrace 'Information Tracking Repository and Collaboration Exchange' to enter and manage requirements, change orders, system objects, system testing and release information.
- Assisted in generating requirements for portion of the eight mandated T-MSIS data files in the standardized formats required by CMS. Eligibility, Provider, Managed Care Plans Long Term Care Claims LTC , Other Claims OT , In Patient IP and Pharmacy Claims RX and Third Party Liability
- Assisted in generating all mandated requirements contained within the CMS T-MSIS Data Dictionary.
- Assisted with source to target mapping of MITS data to the T-MSIS data as required and documented in the T-MSIS Data Dictionary developed by CMS.
- Assisted the testing team in writing test scenarios, test cases and execution.
- Responsible for Facilitating JAD sessions, taking meeting minutes, creating and reviewing business requirements, functional specification and writing Business Requirement Document.
- Assisted with source to target mapping of MITS data to the T-MSIS data as required and documented in the T-MSIS Data Dictionary developed by CMS
- Provided ongoing feedback to all teams and kept continuous communication with the project manager and upper management to make sure the project completion is going as planned.
Environment: MS Visio, Word, Excel, PowerPoint, Share point, iTRACE, Quality Center, Clear Case, Clear Quest,
Confidential is the nation's leading health care services company. They provide pharmaceuticals medical supplies and health care information technologies helping health care providers deliver better, safer care. The project involved developing a web-based medical claims application, which is HIPAA compliant. This application automates the health insurance claims process from the time a claim is received to the time when the claim is adjudicated and fully paid. The implementation of this quality system involved the use of the following ANSI X12 Transaction Sets: 837, 835, 276, and 277.
- Facilitated JAD sessions, which focused on the definition of business requirements associated with Mckesson's claims process.
- Created Use Cases that defined the role of users who receive claims, users who process claims, and users who adjudicate claims. Used MS Visio to develop UML diagrams
- Used Rational Requisite Pro for documenting requirements gathered from business users.
- Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry 270 .
- Utilized EDI Health Care Claim Payment/Advice Transaction Set 835 to make payments, send an explanation of benefits EOB remittance from a health insurer to a health care provider.
- Authored data flow diagrams, sequence diagrams, and business process models that describe how the EDI Health Care Claim Transaction set 837 is used to submit health care billing information and encounter.
- Acted as a liaison by working closely with the development and testing team for achieving milestones.
- Collected test metrics weekly from the Clear Quest in RUP suite database that reflected the current status of the test execution and the state of the defects. Used Rational Clear Case for managing the version changes across all stages of the SDLC
- Worked with the technical architect to design security, interaction, and interface of the application. Also worked with architects to create logical and physical data models.
- EDI Health Care Claim Status Request 276 was used as part of the implementation by Mckesson to request a status of a health care claim.
- Performed manual testing of the functional items by checking a summary of all claims entered and submitted.
Environment: Rational Requisite Pro, Rational Clear Quest, UML, RUP, MS Visio, SQL Server 2000, MS Office, Windows 2000/XP.
Confidential is an independent, non-profit managed care plan that serves the needs of over 210,000 residents of Confidential Area and provides healthcare coverage through its family health plus, Medicare Medicaid programs. The project was involved in upgrading existing health insurance system whereby web-based application and a direct portal would be setup to register Insurance policies for prospective clients.Affinity Health developed New MMIS system for centralizing the all-Healthcare related transactions all over the state. The New MMIS project was a large IT project replacing the Medicaid claims payment system. Participated in all aspects of testing the New MMIS Primary responsibilities was to ensure that the system functions as designed, met the requirements of the business community and conformed to all applicable Federal and state laws. Worked on the claims and provider modules of the New MMIS system
- Interviews with program staff
- Descriptions of the current MMIS system, interfaces, and business processes elicited during the Joint Application Development JAD sessions
- Review of documentation supplied by the Information Technology Department ITD , the Division of Information Technology DoIT , and DHS Medical Services staff, and from the Department of Human Services DHS website
- Worked with HIPAA Team implementation of X12 ANSI 270/271 and 276/277 Companion guides for Pharmacy and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving 837 HIPAA compliance and 835 Remittance Advice.
- Validated the following: 837 Health Care Claims or Encounters , 835 Health Care Claims payment/ Remittance , 270/271 Eligibility request/Response , 834 Enrollment/Dis-enrollment to a health plan
- Worked closely with Business Directors, project managers, business analysts and SMEs in various business areas to gather, analyze and document the requirements and supported the project throughout the development lifecycle
- Automation of test scripts was done using QTP for test re-usability of different online transaction modules.
- Gathered requirements from users of the Clear Quest CQ tool for any Enhancements or change requests for any defects.
- Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835
- Involved in impact analysis of HIPAA 5010 835 and 837P transaction sets on different systems
- Assisted in Regression Test, System Test, and UAT.
- Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
- Created and maintained the Requirements Traceability Matrix RTM .
- Created Use-Cases and Requirements documents to document business needs.
- created Process flow diagrams using VISIO
- Used Quality Center for tracking defects, enhancement requests, assign work activities and assess real status of project throughout life cycle.
- 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
Environment: UML 2.0, MS Office Suite, MS SharePoint 2007, MS Exchange Server, ASP.Net, C , Oracle 10g SQL and PL/SQL , TOAD, Cognos 8.1, MS Visual Studio Team Server-Test Edition.
This intranet website provides the claim status, benefits and account summary to the Health Care Providers. I worked on HIPAA EDI transactions. I worked on Claims processing module of the Group Approval Process GAP . 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.
- Gathered and documented business requirements from Trading Partners, user groups and vendors via workshops, interviews, and surveys.
- Worked in close collaboration with the Project Manager and business users to gather, analyze, and document the functional requirements for the project.
- Worked in Healthcare Claims Administration Healthcare Claims Processing 837/835 includes facility claims and professional claims
- Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 4010 837, 835, 270/271, and others.
- Used the mapping tools to map 4010 and 5010 transactions along with ICD 9 and ICD 10 codes, and validated the HIPAA Syntax.
- EDI Claims Processing documented enhancements to the EDI Claims Processes EDI 837, 835, 276, 277 to ensure accurate processing of claims of members.
- Worked with EDI Mercator Team for Data Mapping and Building 837 Maps
- Work in conjunction with IT EDI group to develop standard product offerings with respect to HIPAA transaction sets 837/835 .
- Followed Workgroup for Electronic Data Interchange EDI standards for testing that need to comply with the HIPAA transaction sets.
- Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
- Involved in setting up the ADT data for Hospital Billing HB team by admitting, discharging, add charge drops and Coding and Abstracting.
- Submitted change requests and worked with change request records in Clear quest.
- Participated in entering, tracking system defects in Rational Clear quest
- Conducted UAT testing writing Test scenarios, test Cases and executed them.
Environment: Rational Requisite Pro, Rational Clear Quest, UML, RUP, MS Visio, SQL Server 2000, MS Office, Windows 2000/XP.
Confidential nursing services, physical, occupational, neurological and speech therapy, home health aides and personal care assistants. The system provides a complete solution for electronic billing and interfaces to EMR software and lab systems. The system includes different packages like Electronic Statement, Electronic Claims billing, and Eligibility Verification. The system was HIPAA compliant and included features like Advance Appointment Scheduler and Eligibility Verification and Referral Tracking.
- Developed Incident documents and portrayed the As-Is reporting structures versus To-be Reporting needs for data integrity and accuracy.
- Worked with Web Sphere message broker for integration of the applications in SOA.
- Performed GAP analysis of 4010 and 5010 EDI transaction using implementation guide to identify the changes in the segments and data elements.
- 277 / 276 Claim request for additional information and response
- 270/271 Eligibility benefit inquiry and response
- 834 Benefit enrollment and maintenance
- 837 Claim and encounters
- 835 Claim payment/Advice
- Part of the team for migration of HIPAA EDI X12 4010 series to 5010 series for EDI Transaction code sets:
- Identified the scope, business objective and documented the functional requirements for each release.
- Directly involved in process improvement Plans and implementing business change.
- Produced clear user manuals training guides for User Acceptance Testing UAT and deployment for end-clients with step-by-step instructions and appropriate GUI screenshots.
- Interacted with the development team on regular basis to ensure and balance practicalities with innovative and efficient business systems solutions
- Created use cases specifications, use case diagrams, swim lane diagrams, component diagram and context diagrams to define the workflow and segregate high-level and low-level requirements using MS Visio.
- Conducted and Participated JAD sessions to gain consensus on various issues related to the project. Acted as a facilitator on different occasions.
- Held regular meetings with the Business users and SME'S to priorities the business Requirements.
- Facilitated the resolution of project-related issues, identified risks, and mitigation steps to manage risk using PLSQL in RDBMS.
- Conducted walkthroughs and code reviews with developers, project managers and stakeholders and users to comprehend business work flow of applications.
- Extensively involved in Database testing by writing SQL queries.
- Used SQL Developer to execute Queries.
Environment: MS-Visio, Pega CM, Windows XP, Oracle, SQL, Facets.
I worked as a Business Analyst on the Health care software FACETS. The application was to upgrade the Facets 4.21 from its previous version 2.96. I was responsible for Requirement gathering and writing use case on the extended application which supports FACETS 4.21 and involved in writing Business rules based on 270/271 transactions and HIPAA Standards.
- 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. Data was collected from end-users, and analysts.
- Created Use-Cases and Requirements documents to document business needs and involved in creating use cases based on HIPAA standards.
- Gathered Requirement from the Client to fulfill the Application need for FACET Implementation.
- Created and maintained the Requirements Traceability Matrix RTM .
- Ensured Use-Cases were consistent and covered all aspects of the Requirements document.
- Refined the requirements use-cases and Business Process Models to detailed level appropriate for technical analysis and system design.
- Was responsible for tracking issues that are detected and updating the status of existing issues based on the daily meetings with the off-shore team.
- Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
- Worked Facets Data Models and their relationship between all functional areas.
- Designed and developed new Interfaces based on business requirements and system's needs.
- Followed Waterfall methodology for the entire SDLC.
- Was involved in, Integration Testing, and User Acceptance Test using the test cases given by the client before releasing the application.
- Interacted with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
- Validated the scripts to make sure they have been executed correctly and meets the scenario description.
- Involved in project status meetings, QA review meeting, and System Test meeting.
- Wrote test cases and test scripts for the User Acceptance testing.
Environment: Mumps Cache, IDX, MS Visio, Word, Excel, PowerPoint, CMMI, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, Oracle, J2EE technology, Java, Perl.
The project involved updating applications that used Transmission files of member records sent by Humana to their partners Providers, Employer Groups, and Clearing Houses . Humana does not send full SSN information to their partners anymore. The partners had applications and systems that used SSN as the unique identifier. This project was to remove the use of 9 digits SSN as the unique identifier for various Third Party processes and Claimants.
- Gathered requirements and documented Use Cases for the applications that used SSN and DOB as unique identifiers.
- Updated displays of YOGI Patient Screen to include masked SSN DOB Information.
- Claims Process Expert Developed Claims Matching Scenarios upon which millions of Claim records were matched daily based on Patient's Information.
- Claims Process Cleanup Involved in cleaning out the previous data and updating applications to accept new format of Claimants Information.
- Created Requirements Document for all the affected processes due to the truncation of the SSN and DOB fields of the Claimants' Information.
- Responsible for handling new conversions for the company so that Claims can be matched and billing records should not create mismatched records despite belonging to the same patient.
- YOGI application Patient Screen Duplicate Claim Number project Updated the YOGI application to include duplicate Claim Numbers in the system.
- Analyzed Business Requirements, developing tracking and enhancing them into functional requirements using Rational Requisite Pro as a requirements tool.
- User Acceptance Testing UAT Carried out UAT activities associated with each project and presented the results to the Business Stakeholders.
Environment: CMMI Level-3 , Rational Rose, Rational RequisitePro, RUP, Test Director, Win Runner, MSOffice2000, UML, Perl, Java.