PROFESSIONAL SUMMARY:

• 7+ years of IT experience as a Business System Analyst with various teams to affect a seamless transition of knowledge and requirements in a SDLC Process.
• Extensive experience in Relational Data Modeling, ER Diagrams, Forward and Reverse Engineering, Publishing Erwin diagrams, analyzing data sources and creating interface documents.
• Extensive Knowledge on Claim Processing: Front End Process (Claims Submission); Claim Adjudication (Auto Pay/Deny/Pending); EOB generation.
• Well versed with HIPAA, FACETS, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Responsible for new customer implementations on the FACETS product.
• Proficient in all aspects of FACETS configuration including eligibility and enrollment, provider reimbursement and network management, referral and authorizations, claims processing, and premium billing and accounting.
• Processes and resolving issues with member attributes, enabling multiple rules associated with member lookup process in FACETS.
• Knowledge and Experience on Membership, Billing, Claims Payment Processing in relation to HIPAA 4010, 5010, ICD - 9 & ICD-10, EDI 834, 837, 270 and 271. 
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Expertise in the configuration provider contract requirements in accordance with reimbursement policies, methodologies and standards.
• Extensive knowledge of code administration including ICD codes, CPT codes, DRG and revenue codes,
• Highly adept in preparing graphical depictions of Use Cases including State Diagrams, Activity Diagrams, Sequence Diagrams, Use Case Diagrams, Component-Based Diagrams, Collaboration Diagrams, Activity diagram, Sequence Diagram, Data-flow Diagram and the Entity Relationship Diagram.
• Extensive knowledge on Group Medicare Advantage HMO and Senior Supplement &PDP.
• In depth knowledge of SDLC and implementation of the Waterfall, Agile and Rational Unified Process (RUP) in all four phases of a project: Inception, Elaboration, Construction and Transition.
• Handful experience in requirement gathering, documenting, verification, validation, analysis and design
• Expertise in conducting interviews, surveys, workshops, JAD sessions by using design modeling tools like Microsoft Visio
• Extensive use of tools such as QC/ALM, FACETS, Rational Suit, SharePoint, DOORs, XML schema, Requisite Pro and JIRA for project management.
• Supported in generating deeply integrated applications and automation system in entire system
• Highly adept in creating various artifacts like BRD, functional specifications, Use Cases, UML diagrams, data mapping documentation, pre and post RTM, weekly reports and validated RFP requirements etc.
• Involved in test planning, test preparation, test execution and issue resolution and report generation to assure that all aspects of the project are in compliance with the business requirements
• Excellent communication, writing and client handling skills to preserve positive and productive client relationships with an ability to handle sensitive personnel related communication and issues with discreteness and sound judgment

TECHNICAL SKILLS:

Business Modeling Tools: MS Visio, MS Word, MS Excel, MS PowerPoint, AxureSoftware Dev Methodologies Rational Unified Model, Unified Modeling Language, Agile Scrum, Waterfall

Testing tools: Quality Center/ALM, Quick Testing Professionals/UFT, Clear Quest

Requirement Managerial Tools: Requisite Pro, Doors, ALM

Database: MS SQL Server, MS Access, Oracle

Language: SQL, XML, HTML

PROFESSIONAL EXPERIENCE:

Confidential, TN

Sr. Business System Analyst

Responsibilities:

• Responsible for preparing Business Requirement Document (BRD), Functional Requirement Document (FRD) and then translating into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Responsible for requirements analysis, design and developing technical requirements.
• Used Agile methodology during the development of the project. Involved in Scrum Calls, Stand up meetings 
• Acted as a SME for the application team and the Infrastructure team.
• Requirement Gathering and Analysis, understanding functional needs, Specification Writing and creating Systems Requirement Document.
• Conducted interviews, meetings, and JAD sessions during the process of Requirement Gathering.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Involved in creating BRD and FRD for Medicaid managed care requirements and documenting them.
• Worked in creating and verifying EDI transactions for Medicaid (MMIS) and Medicare claims.
• Created swim lane diagrams for “As-Is” and “To-Be” Business Process Flow using MS Visio.
• Worked closely with the project team to identify use case dependencies and planned the use case development.
• Involved in PowerMHS Implementation, involved end to end testing of PowerMHS Billing, Claim Processing and Subscriber/Member module.
• Generated all Medicare claims review and transmitted to Medicare.
• Worked on 837, 835, 276 and 277 Institutional and Professional EDI Gateways.
• Validated X-12 files sent by external vendors to ensure that they are passing EDI Gateway level using Spec Builder.
• Worked on multiple 837 and multiple Eligibility (270/271) and healthcare claim status (276/277). 
• Involved in development of claim management to assist claim professionals to analyze and administer the Medicaid and Medicare claims in an efficient manner.
• Involved in impact analysis of HIPAA EDI 835 and 837P transaction sets on different systems.
• Coordinated with corporate Enterprise Data Warehouse (EDW) effort for impact of conceptual enterprise data model (EDM) to production LDMs.
• I have interacted with DBA for the process of data extraction, data transformation, data load, data integration and conversion processes using business intelligence tools.
• Assisted the Director of Medicare and Manager in creating various ad hoc reports using Microsoft Access and Excel applications. 
• Assisted with CMS Date validation, Medicare and full scale audits.
• Checked all processed Medicare Advantage and Medicare Cost applications and enrollment change forms for error.
• Used MS Visio to create Business Flow Diagrams and Work Flow Diagrams to illustrate the structure of the system and the relationship amongst its various components.
• Maintained Requirement Traceability Matrix (RTM) and managed requirements.
• Documented Business processes and data flow using Process Flow and Data Flow diagrams in Microsoft Visio and PowerPoint presentations.
• Responsible for managing the Data Warehouse and Business Intelligence functions.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Developed SQL queries, functions, stored procedures and triggers to perform the backend testing of the data.
• Performed backend testing to check the system data integrity for insert, update, delete and retrieve transactions by being involved in writing complex SQL queries including joins, group by, having clause etc.

Confidential, Amherst, NY

Business System Analyst

Responsibilities:

• Performed Requirements Gathering and Analysis, interviewed the SME (Subject Matter Experts), and ensured that contributors and all key stakeholders were motivated to complete assigned tasks.
• Prepared the Business Requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Facilitated Joint Application Development (JAD) Sessions for communicating and managing expectations.
• Worked in Scrum teams and facilitated grooming sessions to identify and prioritize user stories.
• Gathered high level requirements from the business, created user stories, and prioritized the backlog with project manager.
• Incorporate Agile to create Business Requirement Document Specifications using MS Visio and MSWord.
• Assisted in the development of HIPAA and other regulatory requirements for the department/area.
• Created Process Work Flows and responsible for preparing Functional Requirement Specifications.
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the proposed system.
• Ensured system configuration and functionality adheres to HIPAA 5010, Medicare, Medicaid other market-specific regulations and business rules.
• Used Data warehousing for Data Profiling to examine the data available (Data Analysis) in an existing database
• Maintained knowledge of Medicare and Medicaid rules and regulations pertaining to the s configuration and evaluating the impact of proposed changes in rules and regulations.
• Worked on EDW gaps which came into existence after small group migration for EDW client on subject areas like product & group.
• Recommend ways and workarounds for HIPAA 5010 (EDI X12 837,834, 820, Reviewed HIPAA 270/271, 276, 277, 835, 837, and 820 standards for the process and products developed.
• Created Use Case diagrams by analyzing the business process followed by Activity diagrams using MS-Visio and participate in production of HIPAA 5010 EDI Test data.
• Produced Gap Analysis documents for HIPAA 5010 and ICD 10. 
• Did Presentations making Stakeholders understand how the changes would affect different modules w.r.t. Medicare and Medicaid.
• Involved in claim adjudication process of facets application.
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system).
• Involved in claims submission and payment (remittance) retrievals by using ASCX12N 820 for the In- bound premium payments; ASC x12N 834 for the Inbound Enrollment and Maintenance; ASCX12 276/277 for the claims status enquiry and response; and ASC X12 835 for the Health care Claim Payments.
• Worked on Data Mapping to map Facets data to outbound eligibility extracts.
• Worked on FACETS subsystem such as billing and enrollment.
• Performed complex defect reports in various environments like UAT, SIT, and QA etc to ensure the proper delivery of the application into the production environment.
• Formulated system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes such as HIPAA/ EDI formats and accredited standards. 
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. 
• Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins.
• Designed and developed various Ad hoc, Daily, Weekly, Monthly and year-end reports for the Business Analyst using SQL, Ms Excel, Ms Access and Teradata.
• Experience in Data Validation, Data Modeling, Data Flows, Data Profiling, Data Mining, Data Quality, Data Integration, Data Verification, and Data loading.
• Gathered business requirements by conducting meetings with presentations with stakeholders and business users using Visio and PowerPoint.
• Used SQL, Data Warehousing and Data Cleansing for the arrangement of customer data. Used Data mapping for collecting the data.

Confidential, Bronx, NY  

Business Analyst

Responsibilities:

• Assisted the project manager in the creation of the project charter & vision document during the inception phase of the project.
• Assisted the project manager in the creation of the project charter BRD, FRD & vision document during the inception phase of the project.
• Performed GAP analysis as it pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process.
• Produced Activity diagrams with defined swim lanes as part of the claims process analysis.
• Worked on developing the business requirements and use cases for Facets batch processes; automating the billing entity and commission process.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization.
• Used TriZetto HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (270, 276, 278, 834, 837 (I, P, D) standards.
• Involved in end to end testing of Facets Billing, Claim Processing and Subscriber/Member module.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases.
• Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments.
• Created a detailed use case scenario.
• Created Wire Frames for the Confidential System/portal used for showing claims process in Facets.
• Led and managed the User Acceptance Testing (UAT) for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that HIPAA regulations are met across all the modules
• Assisted the Quality Analyst (QA) in creating test plans, test data and conducted manual testing to validate functionality.
• Clarified to claims personnel the new Affinity payments and Explanation for payments (EOPs) for same claim processing cycle.
• Clear understanding of Medicare (Part A, Part B and Part D) and Medicaid benefits.
• Assisted the QA in performing simple SQL queries for QA testing and data validation.
• Conducted user training pertaining to old and new Affinity Provider ID appearing on documents providers receive from Affinity (mainly occur with EOPs, capitation rosters, PCP membership rosters, provider directory listings and some system generated letters). 

Confidential, Nashville, TN

Business system Analyst

Responsibilities:

• Systems Documentation included Business Requirements Document (BRD), Systems Requirement Specification (SRS) and test plans using Requisite Pro.
• Worked on Member Management, Eligibility, Claims, and Provider modules within FACETS.
• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, premium billing, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc. from Legacy system to FACETS.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Coordinated between communication channels to keep key stakeholders and team members apprised of goals, project status, and resolving issues and conflicts (meeting facilitation, JAD sessions, collaboration workspaces, project reporting).
• Reviewed and gathered requirements from the Subject Matter Experts (SME) and Business Partners using various elicitation techniques and create Scope Management Documents.
• Tested the Registration process of common practitioner in Facets and validated the fields (Medicare or Medicaid billing number, License and DEA number).
• Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions include 837, 835, 276, 277, 270 271 - (both inbound and outbound) transactions
• Worked with Trizetto Facets claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
• Coordinated with the different teams distributed at different geographic locations for various releases.
• Formed advanced SQL Queries and used Microsoft Excel to investigate data issues in the Data Warehouse and worked with the Users and Technology Team to formulate a solution to resolve the issue.
• Performed backend testing to check the system data integrity for insert, update, delete and retrieve transactions by writing complex SQL queries including joins, group by, having clause etc.
• Created workflow diagrams, process flow and data flow diagrams.
• Created new, and modify existing SQL queries for use in the data integrity testing of the data warehouse application's ETL process.
• Used Microsoft Word, Excel, Access and Visio as working tools.
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio
• Involved in creating use case diagrams for the purpose of the team to understand the workflow of the system.