Dynamic and result-oriented Business Analyst with 9 years of experience in delivering business, technical and systems solutions for the healthcare industry with excellent technical and leadership skills.
- Extensive experience in vetting business requirements using elicitation techniques like brainstorming, focus groups; Facilitating JAD and JRP sessions, User Stories and use cases. Translating requirements into BRDs and technical specifications and functional requirements (FRS).
- EDI Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/270/271 processes of EDI Medical Claims Industry from the Provider/Payer side.
- Excellent knowledge of all the phases of the Software Development Life Cycle (SDLC), Test development life cycle (TDLC), Project Management life cycle (PMLC).
- Experience in HIPAA 5010 and 4010 transactions as well as ICD9/ ICD 10.
- Experience working on Provider data management for Provider attributes like networks, locations and specialties for Individuals and Hospitals.
- Adept in creating Business Process Models, Data Flow Diagrams using UML modeling tools like MS Visio.
- Excellent knowledge of different Software methodologies such as Waterfall methodology, RUP & Agile/ Scrum.
- Working experience as Software Quality Assurance. Expertise in writing Test Plans, Test Procedures, Test Cases, Test Scripts, Requirement Traceability Matrix, identifying different Testing Techniques, identifying and tracking defects and conducted Manual and automated testing.
- Experience in performing SWOT analysis, Root Cause analysis, Cost Benefit analysis, GAP analysis and project planning and scheduling. Created Mapping documents.
- Experience working with Data Migration from Legacy systems to advanced relational databases, Data Conversion, Data Archiving into Central Repository/Informatica Servers, Merging records in Master Database Management (MDM).
- Proficient in SQL and PL/SQL Programming for testing database integrity.
- Experience working with Prescription benefit Manager (PBM) which provides cost effective drug distribution and claim processing for payers.
- Worked with Pharmacy NCPDP EDI standards Version 5.1 and D.0 claims for Medicare and Medicaid process.
- Worked with Troop & Drug Spend and other adjustment financial calculations adjusted by the PEGA applications for Medicare claims. Experience with Pega WorkList and WorkBasket functionalities
- Well experienced with the offshore-onsite IT services model.
- Complete SDLC experience from requirements to post production support.
- Strong team building, time management, meeting management skills and a good team player with excellent written and oral communication skills and can write for technical and non-technical audiences
Business Tools: Microsoft Office Suite (Word, Excel, Power point, Access, Project and Outlook), MS Visio, MS Project, Rational Suite, PEGA 5.5/6.1 ,Requisite Pro, Optimal Trace, Caliber RM, Caliber RMD.
Test Automation: Quick Test Pro
Test Management: Mercury Test Director, Quality Center, IBM Rational Clear Case, Clear Quest, Load Runner
Process Methodology: SDLC, RUP, Waterfall and Agile/Scrum frameworks
Others: In-house, TIBCO (BW 5.8 BC 5.6), NASCO, FACETS v4.7.1, v4.8.
Databases: SQL Server 2000, Oracle 10g, MySQL, MS-Access and DB2
Operating Systems: Windows 2003 Server, 2000, NT, XP, 95 / 98, UNIX
Web Servers: IIS 5.0/4.0, MTS, Personal Web Server
ETL Tool: Informatica 8.6
Reporting Tool: OBIEE 10.1.3.3.3
EDI Mapping Tools: EDIFECS, ClarEdi Classic
Confidential, New York, NY
Role: Senior Business Analyst
New York City Confidential is a department of the Government of New York City responsible for public health along with issuing birth certificates , dog licenses, and conducting restaurant inspection and enforcement. As a senior business analyst I was working on the following projects.
Pest Control System (PCTD) – The Division of Informatics and Information Technology (DIIT) is part of Confidential and Mental Hygiene. Working on an existing PCTD web application and handheld/tablet solution that will synchronize mobile data to a staging database which will be uploaded to the PCTD web application dynamically. The system handles all the daily business operations for the Bureau of Veterinary and Pest Control Services, including receipt and triage of complaints, inspections, follow-up inspections, clean-ups, notifications and tribunal actions.
BMS – Budget management System is DOHMH's technology solution to manage and track the Agency's 5-year OTPS, PS, Grant, and Capital budgets. The system will provide comprehensive management reports, audit trails of all changes, extensive workflow and integrate with other internal DOHMH financial systems. This system will allow the Agency to easily and automatically roll-out the fiscal year budget and provide insight into out-year budgets.
- As lead analyst was responsible for gathering requirements of the new enhancements in the PCTD project. Facilitated various JAD sessions, portrayed as a scribe to record and keep track of all the activities within the project and defined the scope of the application.
- Measured risks/impacts for technical and business challenges for remodeled Materialized views and load process including file transfers, direct loads etc. These include data extracts and implementing existing or new transformation rules for existing interfaces.
- Created Data mapping documents for ensuring the accurate link between the Source and the target entities within the tablet solution.
- Responsible for writing and reviewing the BRD/FRD documents, 'As-Is' / 'To-Be' Process flows with the Core team, Business owners, SMEs and all required signatories.
- Worked extensively with the SQL server to understand the data staging and used TOAD to check the data integrity of the tablet solution/
- Worked with data integrity team and providing them guidance thru implementation of business verifications and business rules/edits.
- Developed use cases for report creation, storage and uploads of the daily operations of the BAU, PCTD and DOHMH systems
- Created Swim lane diagrams for audit trails in the BMS project.
- Documented requirements on the creating the Google map key using MD5 fingerprint.
- Experience working with the data base schema for the complete application and served as a single point of contact for all the business details for audit trails.
- Familiarity with Informatica Workflow Manager and Monitor Applications, Informatica Designer applications
- Extensively worked with data modeling for capturing requirements for Database design for developing datamarts.
- Conducted manual testing and logged defects using Clear Quest. Assisted testing team in understanding the business rules and system development. Created users and user groups to assist testers.
- Used SQL for back end testing and ensured the data is updated accordingly.
- Developed test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
Role: Senior Business System Analyst (BSA)
Horizon BCBS is New Jersey's largest health care management providing health insurance to 3.6 million members and best known for its Managed Care and traditional indemnity plans for individuals and employers. As a Senior BSA, I worked on the following projects
PNO: One of the lead business system analyst in Provider Network Organization (PNO) 5.3.0 to 9.0 application upgrade and wizard optimization project which includes operational enhancements and optimization of front-end wizards.
IDS/MDM: Horizon is introducing enterprise level strategies like MDM (Master Database Management) and DG (Data Governance), the source of provider data feeding to the downstream applications and vendors is changing from the legacy system PNO to IDS (Integrated Data Store).In order to continue feeding the downstream interfaces, the feed from old source has to be re-designed and remapped to the new source of provider data.
HCR: As a part of united states Health Care Reform (HCR) Project federal statue of Patient Protection and Affordable Care Act 2010, individuals are entitled to purchase health insurance eligible for federal subsides.
VBN: Horizon will introduce a Value Based Network (VBN) strategy a new product that encourages members to seek healthcare services through primary care providers. Horizon Patient-Centered Medical Home(PCMH) and Accountable Care Organization (ACO) primary care provider partners are financially incented through innovative payment strategies.
HCM: ICD-10 Health Care Management (HCM) Federal Regulation Mandate requiring the adoption of ICD-10 Diagnosis (CM) and Surgical Procedure Codes (PCS) on HIPAA transactions for services on and after October 1, 2014.Horizon will optimize process, improve system transactions and utilize a richer data set to incorporate ICD-10 enhancements while maintaining the ICD-9 functionality.
- Involved in remodeling and feasibility assessment, for downstream feeds and Interfaces like NASCO, iCore, Care Core, Informatics, ITS, and HLGS and that were impacted as part of the PNO migration.
- Performed affinity analysis, data conversion and migration and remapped the feeds from the old source PNO to the redesigned new data source IDS
- Extensive Gap analysis between Integrated Data Store and Legacy systems for specific Interfaces for the Provider data.
- Performing Impact analysis for readiness of ICD-10 conversion.
- Performed Analysis of ICD 9 Procedure and Diagnosis Codes in accordance with ICD 10 CM and ICD 10 PCS Conversion Compliances. Gathered requirements for impact on NASCO Provider Interface to identify the impact on claims processing with ICD-10 codes
- Responsible for coordinating among various teams and clients to ensure accurate migration of data by creating Data Mapping Document and created roadmap for transition from current state to future state.
- Prepared Data Affinity analysis between the legacy system PNO and new Source systems MDM and IDS, and also ran reports to perform data comparisons and cleansing.
- Worked extensively with MDM and IDS team in the process of data cleansing, data conversion and data migration. Also merging of provider records from various resources into one golden record in MDM.
- Extensively used SCRUM process to analyze the provider data in the current source and Agile Methodology in the process of the PNO Wizard Optimization project management based on SDLC
- Developed detailed test cases for NASCO (NAPS, POD, NART sub-systems) and test scripts and assisted the SQA with system integration testing and user acceptance testing (UAT), developing and maintaining quality procedures and ensuring that appropriate documentation is in place
- Involved in data dictionary management, and ETL of data from DAL (Data Access Layer), which was essentially a layer of materialized views built on top of the IDS framework. Participated in ETL requirements process during data transition from source systems to target systems.
Confidential, Franklin Lakes, NJ
Role: Sr Business Analyst
Confidential is a leading pharmacy benefit manager (PBM), with the nation's largest mail order pharmacy operations. Confidential Health Solutions provide myriad services for private and public employers, health plans, labor unions, government agencies, and individuals served by Medicare Part D Prescription Drug Plans. As a senior Business Analyst I was involved in various projects around CMS compliance, Medicare, Medicaid, Subrogation plans, worked extensively on new product/plan design project for Enhanced groups.
- Worked on numerous projects as a lead analyst and was primarily involved in the chartering and analysis phases of the project.
- Facilitated all the meeting with the key player in order to run a JAD session to analyze and gather requirements.
- Authored BRD /FRD documents in a use case format via Micro focus Optimal Trace tool (v 5.4).
- Conducted various Cross functional reviews and Review Records required to support CMMI level 3 environments and improvement of the SDLC (Software Delivery Life Cycle) process.
- Developed various Quality phase gate documents and familiar with the CMMI SDLC process.
- Worked extensively on subrogation project for Medicare Part D to ensure Confidential complies with CMS guidance by creating a recovery/reconciliation process in NCPDP EDI standards Version 5.1/D.0 environment.
- Involved in various complex custom client requirements for new capabilities and product enhancements to compete in the marketplace and will be critical to retention and new business.
- As a part of new product design, worked extensively on custom Member Eligibility requirements to clients like Confidential , BCBS Michigan, Duke, Chevron etc.
- Key scribe in various critical analysis discussions on enhancement, compliance and new product design projects under Confidential PDP and BOB.
- Was responsible in gathering the requirements for Client front end applications, Customer services applications and also on custom reports posted to Client websites.
- Worked with NCPDP 5.1 and D.0 Mail/Retail/direct claims, 835 transaction claims.
- As Lead Analyst was involved in various projects which includes Adjustments of Claims a critical analysis
- Responsible for managing the change controls, worked closely with development and testing teams to estimate the impact within a strict delivery dates.
- Identified and vetted requirements for financial (Billing, Pricing, Invoicing) projects, Member website projects, Project involving enhancement of Drug Utilization review, Explanation of Benefits (EOB), Audit processes and Adjustments in PEGA environment.
Confidential, Philadelphia, PA
Role: Sr Business Analyst / QA Coordinator
Confidential offers quality health care products and services designed specifically to meet the changing health care needs of customers. As a Business Analyst I was involved in HIPAA 5010 Project. It includes new claim processing systems CIS for IBC for HIPAA 5010 EDI transactions. The environment used is Agile/Scrum methodology
- Worked with Business Users, technical teams in getting the sign-offs for BRDs, FRDs.
- Conducted JAD sessions, structured interviews, one on one gathering session in order to understand custom client requirements while implementing the 5010 analysis for their 837 and 835 transactions, Medicare & Medicaid claims
- Responsible for the entire walk through for Functional Specs to development team and QA team.
- HIPAA 5010 837I/P, 835 CIS enhancements were prime focus of this project.
- Responsible for conducting daily touch point meetings for HIPAA 5010 project with business, development and testing teams in this Agile/scrum environment.
- Involved in converting 4010 x12 to 5010 and creating test data for QA team for 5010 HIPAA 837I/P Claims, 835 transactions.
- Analyzed customer needs and existing functions in the area of HIPAA 4010/5010 Claims to determine feasibility, consistency with the established scope of work.
- Worked with Various Line of Business (LOB) Like AHA (AmeriHealth), Medicare Crossover, Planmate, MHS
- Performed requirements gap analysis and linked QC requirement to test scripts.
- Experience working with Mainframe environment like TCO and ISO for Provider verification data.
- Responsible for Manual testing various claims and logged defects using Defect Module in Quality Center.
Confidential, Cleveland, OH
Role: Business Analyst
Worked as a consultant with Confidential as a Business Analyst. Analyzed and tested business workflows that organize and integrate clinical information for each of its member’s clinical records, pharmacy information, charts, and clinical practice guidelines
- Worked with Business users and technical lead for gathering requirements and data transaction information.
- Created Questionnaire Document and Work Agenda before the JAD sessions.
- Conducted JAD Sessions periodically with various stakeholders at various phases of the Software Development Life Cycle (SDLC) to discuss open issues and resolve them.
- Created the business process model using MS Visio for SME’s for validation and getting the sign-offs
- Identified Claims management work flows, business rules and developed flow charts and activity diagrams
- Experience working with the EDI transaction sets 835, 837, 270/271, 278 which include Referrals/Specialty Care Claims.
- Involved in the Payer Cycle such as in the enrollment, CCMS memberships, benefits management claims processing, provider servicing, and member servicing and ad-hoc reporting.
- Data conversion of all EDI claims from 4010 ANSI to 5010.
- Created 5010 p references for all the HIPAA real time & batch transactions.
- Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
- Extracting special Claims to test for MSP( Medicare secondary payer)
- Provided Support services for Centers for Medicare and Medicaid Services (CMS)
- Configured FACETS to adhere to customers work flow for claims processing, claims automation and group administration
- Used FACETS to provide seamless transactions between the provider, members and the plan and used FACETS Workflow to route the claims according to the priority.
- Responsible for monitoring the Production Batch jobs for data loading via Information ETL tool.
Confidential, Bethesda, MD
Role: Business Analyst
Confidential operates health plans, insurance companies, network rental and workers’ compensation services companies. Confidential provides a full range of risk and fee-based managed care products and services to a broad cross section of individuals, employer and government-funded groups, government agencies, and other insurance carriers and administrators.
- Responsible to insure that EDI Process is HIPAA (Health Insurance portability and Accountability) compliant and worked on ANSI X12 standards.
- Analyzed URS and Functional Requirements Specifications to understand business rules of application.
- Identified the scenarios based on business requirement and HIPAA compliance for each transaction such as 837(Claim) and 276/277 (Claim Status).
- Generated activity diagrams and developed design specific constraints such as interface type or security level using optimal trace.
- Performed data analysis and converted member IDs (PID) to alternate member IDs for all of the MS Access databases used by Claims system.
- Experience working with Nasco Adjudication Processing system. Was responsible for claims routing in Nasco System. Worked with Client Eligibility Module, Pricing, Utilization Review and COB processing
- Involved in Nasco File Edits validation of data in a sequence that ensures the legitimacy of the system edits to follow.
- Processed Medicare claims and worked on EHR as a web based application.
- Mapped EHR records to flat files from various vendors.
- Performed Data mapping, logical data modeling and used SQL queries to filter data within the database tables.
- Involved in Data Selection for testing the EDI Load Process: backend process for loading and processing the data received through EDI and manual process as per Business Rules.
- Participated in Testing using SQL queries on SQL Server tables and generating ad-hoc reports to ensure data integrity.
- Performed UAT testing with client and supported all phases of testing with QA team and managers
Confidential, Salt Lake City, UT
Role: Business Analyst
Worked as a BA in the Confidential where I made changes to the existing payer system used for processing claims. Inclusion of the ICD code and billing code were also a part of the project to assign specific code to the disease injury to make it more consistent and precise to that of the provider’s information as a part of the claim process.
- Developed and executed strategic initiatives and programs to enhance existing and Medicare claims processing functions in support of corporate initiatives and requirements.
- Working knowledge in ICD 9 ANSI Health codes HL7 in the claims environment for inpatients and outpatients, reviewed the implementation of the changes made in the systems as per the formats and compliance for EDI usage.
- Used EPIC software for tracking and updating the claim report project and provided guidance in the investigation and final disposition of complex claim matters from Executive Senior Management through JAD sessions for analysis and design.
- Used the RUP methodology and related processes for software re-engineering process. Monitored claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and departmental goals.
- Involved in writing USE cases and prepared the Business Requirements Documents for various requirements collected from the business users. Used MS Visio and UML for generating class diagrams and activity diagrams.