Summary of Qualifications :

• An accomplished IT Professional with Eight 8 years of experience as Business Systems Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling.
• Experienced working on 4010 and 5010 HIPAA implementation guides relate to Claim Testing and Medical Billing
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services .
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
• Familiar with HIPAA Standards and Compliance issues, HIPAA Privacy policy.
• Requirements gathering in compliance with HIPAA 4010 and 5010 standard.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Knowledgeable in facets.
• Involved in GEM (General Equivalence Mapping) tools for forward mapping of ICD 9 – ICD 10 codes as required by the project.
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document ( BRD ) and Functional Requirement Specifications ( FRS ) document.
• Facilitated one on one interviews, Joint Requirement Planning ( JRP ) and Joint Application development ( JAD ) sessions
• Experienced in methodologies like Agile , Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Involved in maintaining performing GAP analysis, Requirement Analysis, Document Analysis.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claims adjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277)
• Thorough knowledge about Facets.
• Good knowledge of SQL queries, writing test cases, test plans based on the requirements.
• Highly motivated, analytical, pro-active, organized and target-oriented team player with strong interest in Business System Analysis. Proven ability to support multiple complex projects under tight deadlines, often with competing priorities

Technical Competencies :

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management Tools: Rational Requisite Pro, Rational Rose, MS Visio, HP ALM

Operating Systems: Windows 2000/7/XP, DOS

Languages/Standards: SQL, HIPPA 4010/5010, ICD9/10

Methodologies: Agile, Waterfall

Professional Experience :

Confidential

Role: Sr. Business Analyst

Worked in an internal project, Escalation and Reconciliation Management System (ERMS) initiated to help the end users to get their personal information easily. I was supporting the Requirements Manager and Team Lead to gather requirements and update information as needed.

Roles & Responsibilities:

• Performed requirements gathering and analysis, ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
• Maintained a very close interaction between IT team, developers, Project manager to avoid any gaps in understanding or implementation of requirements.
• Worked closely with the project team in planning, coordinating and implemented QA methodology on various phases of the application.
• Interacted with the technical team for the claims transactions design.
• Performed GAP Analysis for new functionality requirements and prioritized them based on the business needs
• Created workflow diagrams, UML diagrams, use cases, process flow diagram, test cases and test plans.
• Managed the Requirements (Business as well as System requirements), performed requirements analysis along with the creation of Use Case Scenarios.
• Gathered Business/Functional Requirements from Business/R&D Users.
• Worked with the development team to make sure that they understood the user requirements and that the system developed met those requirements.
• Participated in developing test plans templates and guidelines to be used by the project team with detailed screen layouts with regards to various types of corporate actions.
• Completed a thorough customer analysis and prepared a Request for proposal (RFP) document and got the shortlisted vendor document signed off. Finally CRM(Customer Relationship Management) was decided upon by the stakeholders among shortlisted as final implementation customer
• Involved in User Acceptance Test as needed.
• Involved in the development of Test Plans and Test Cases and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Created manual Test Cases in HP QC/HP ALM for various User Stories based on Release and Sprint Plan.
• Worked with the Project Manager on various Project Management activities like keeping track of Project Status and Deadlines/Milestones.
• Conducted the initial study of Health Care Management to collect customers’ information like data about existing systems at customer site, specific customer requirements.
• Involved in Business Process Reengineering (BPR) - analyzed existing business processes and implemented new improved processes.
• Co-authored detailed Business Requirements Document and Functional architecture and solution Specification Document.
• Highly involved with Unit testing, System testing and Integration testing.
• Experienced working on 4010 and 5010 HIPAA implementation guides relate to Claim Testing and Medical Billing
• Used Facets for claims processing for the given project.

Environment: MS Office, SQL, Agile, GEM, ICD manager, Enterprise Code, Rational Rose, Oracle

Confidential, Virginia Beach, VA

Role: Sr. Business Systems Analyst

Confidential is of the one largest Medicare and Medicaid provider in the country. They focus on providing insurance service to everyone through various publicly sponsored programs. The goal of the project was to create standardized eligibility extract from Facet and securely transfer them to corresponding vendor.

Roles & Responsibilities:

• Involved in handling HIPAA/EDI Medical Claims, design and documentation
• Monitored and Analyzed activity report and transaction monitoring.
• Created document and diagrams for membership enrollment according to HIPAA 834 compliance standard for membership enrollment.
• Conducted meeting with the development team to discuss any requirement changes.
• Checked inbound/outbound HIPPA regulated EDI transactions facets
• Conducted business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports
• Involved in GEM (General Equivalence Mapping) tools for forward mapping of ICD 9 – ICD 10 CM/PCS codes.
• Involved in Manual Testing and UAT testing.
• Prepared BRDs (Business Requirement Documents), Functional requirement documents, supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze data requirements from Data ware house.
• Performed GAP analysis of business rules, business and system process
• Designed Activity, Sequence and process flow diagrams using MS Visio to simplify and elaborate certain selection and filter condition.
• Documented requirement using Use Case analysis.
• Conducted JAD session, meetings, and information sessions to gather the requirements from the clients.

Environment: UML, RUP, Rational Requisite Pro, Rational Rose, Facets, Excel, SQL

Confidential, Durham, NC

Role: Sr. Business Systems Analyst

Cigna Healthcare is a company providing customers with benefits, expertise and service that improve the health, well-being and productivity. As a BA, I was involved in developing fully automated, real-time claims processing system for complete, on-line mediation of medical, dental, vision, and disability claims and encounters as per HIPAA guidelines. System allowed the efficient and timely management of all relevant data clinical, financial, and administrative throughout the organization enabling the sharing of information between subsystems.

Roles & Responsibilities:

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements.
• Designed a claim processing system for the healthcare management client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms (ICD-9 codes), and treatment (CPT).
• Responsible for gathering the functional requirements for the health benefit claims receiving and processing system.
• Conducted requirement gathering sessions with the purpose of creating and defining the Business Requirement Document (BRD) and the Functional Requirement Document (FRD) using Rational Requisite Pro.
• Involved in Requirement Scoping and analyzing high priority requirement. Conducted sign-off meetings with IT teams to lock down the requirements.
• Created high-level Use Cases from Business Requirements and created UML diagrams like Use Case and Activity diagrams using MS-Visio.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives with each other, resolve any issues and come to an agreement quickly.
• Tracked stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Involved with the following list of HIPPA-EDI Transaction Code sets: 837, 835, 270/271,277/275 and 276/277
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Involved with the Quality Assurance Team to develop and design test plan and test cases.
• Executed test cases and test scripts for manual and automation testing. Defects are raised in the HP Quality Center/HP ALM for logging, tracking and reporting bugs in the application.
• Conducted User Acceptance Testing (UAT) of the application with the QA team.
• Performed testing of the health benefit claims receiving and processing system to ensure that the system adheres to project standards, performance criteria, and functional specifications.

Environment: MS Office Tools, Windows XP, Facets, MS Project, SharePoint 2007, MS-PowerPoint, SQL, Agile framework.

Confidential, Tampa, Florida

Role: Sr. Business Analyst

Humana’s project involved the creation of processes, procedures and technology for the compliance with HIPAA 5010 and ICD 10 standards. I was involved in the analysis of the required changes needed in the existing system of Humana. Part of my job was to analyze how changes in field length, type and values would have an impact on present systems and how to prepare the present systems for these changes.

Roles & Responsibilities:

• Involved in gathering requirements as per the consensus meetings between Humana and providers.
• Created domain models and made them an integral part of multiple FRDs that I created for various aspects of the project.
• Utilized survey assessment results of ICD-10 to create listing constraints, processes, projects and systems, applications and vendor software to be impacted by the ICD-10 Conversion Project.
• Developed Use Case diagrams and process flow diagrams using Rational Rose and MS Visio.
• Actively prioritized and managed requirements throughout SDLC with all key stakeholders
• Negotiated and managed multiple priorities, project plans, time frames and trade-offs while ensuring the clinical and administrative staff understood the final results of the projects, sharing detailed vision of cost-benefit analysis.
• Provide input to estimates for project management and change management activities through analysis of requirements effort, resources, and technology.
• Worked on EDI 834, 835,837 as per HIPPA guidelines.
• Performed the detail comparison between 4010A and 5010 especially in regard to EDI 837.
• Help in preparing the training material of the providers and insurance companies using the software supporting ICD 10.
• Used the Agile methodology for the application development and created Use cases, activity diagrams and drafted UML diagrams.
• Worked on cross-functional team to deliver software systems as per the customer expectations.
• Updated the requirements and prepared comprehensive Business Requirements Document (BRD) that provided the appropriate scope for the users and management to make appropriate decisions.
• Created Data Flow Diagrams (DFDs) and ER diagrams for domain modeling.

Environment: Project Life Cycle (PLC), SQL, MS Visio, MS Project, Oracle