SUMMARY:

• Healthcare Business/Quality Systems Analyst with more than 5 years of experience in the HealthCare Industry.
• Business Systems Analyst with hands on experience in business consulting in healthcare and application development with excellent skills in client interfacing, requirement gathering, user support, quality assurance, problem solving, and documentation.
• Skilled in determining system requirements and specifications for complex application development projects. Current experiences of leading and interacting with business teams, programmers and technical staff at all levels.
• Experience in creating and maintaining the Requirements definition documents that included Business, Functional and Technical requirements.
• Expertise in all the phases of the Software Development Life Cycle (SDLC), Agile Development methodology.
• Experienced in conducting brainstorming sessions, reviews, and walkthroughs and customer interviews (UAT) for various business processes.
• Good understanding of healthcare industry - claims management process, Medicaid and Medicare Services and insurance sector.
• Expert in Healthcare Payer systems - Claims, Billing with backend data mapping, data integration.
• Exposure in creating and analyzing Data Flow diagrams, and Entity Relationship diagrams (Visio).
• Skills to track environment build release level at various point in the software building process.
• Possess Project management skills such as time estimation, task identification, risk analysis and scope management and resource management.
• Good practical knowledge in understanding Medicare Concepts, detailed knowledge of the claims adjudication process within a healthcare payer.
• Using RI Healthcare Portal for various health insurance areas such as enrollment, eligibility, member opt out, Claims and other related modules.
• Defining Test Cases, executing, analyzing bugs and interacting with team members to fix errors, Unit testing, System Testing and User Acceptance Testing (UAT).
• Using Bugzilla Application to log the bugs into the system and let the team work on the fix and retesting.
• Attended testing status calls to update corporate on our testing progress and address any testing concerns.
• EDI Claims Processing - documented enhancements to the EDI Claims Processes (EDI 837, 835, 276, 277) to ensure accurate processing of claims of members.
• Highly motivated and organized; results & detail-oriented with excellent interpersonal, communication, and presentation skills.
• Experience with Provider Electronic Solution (PES) Application: Claims Processing, Recipient Eligibility, Medical Plan, Provider, Utilization Management.
• Experience with POS Claims submission to test the real-time claim progress through the application.
• Experience with TOAD, running multiple SQL queries on multiple environments for building, updating, testing and verifying.
• Experience with FileZilla and UNIX - loading, transferring and retrieving files from sftp servers.
• Good understanding of a Testing process.
• Strong knowledge of Project management skills such as time estimation, task identification, and scope management.

TECHNICAL SKILLS:

Methodologies:  SDLC, Agile, Waterfall

Business Modeling Tools:  Microsoft Visio

Technical Tools:  TOAD, UNIX, FileZilla, mRemote, PSPAD

Platforms: Windows

Testing tools: PES, POS, Bugzilla, HCP, IWS, MS Excel

Office Tools: MS Office, MS Visio

Version Control Systems: Scripting, Rational Clear Case

Database: MS SQL Server, TOAD and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Warwick, RI

Business/Quality Systems Analyst

Responsibilities:

• Assisted the project manager in the creation of the project charter & vision document during the inception phase of the project.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business requirements, Functional requirements to Technical specifications.
• Performed Gap analysis for the new functionality requirements Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Documented the Business Design Documents with required Appendices for Core and Notices section of the project.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization.
• Derived Functional, Non-Functional, Informational Requirements and Business Rules in accordance with the project scope.
• Scheduled the Internal and External Walkthroughs for BDD and get it approved.
• Reviewed the Technical Design Document to verify the Technical design based on the Business logistics.
• Created Test strategy, Test Plan and Test Count Script based on the Excel Test plans (Macro).
• Created the data dictionary for the entire data field and their location.
• Created Test Cases that defined the role of users who receive claims, users who process claims, and users who adjudicate claims.
• Responsible for System Test execution and logging the Bugs and retesting and verification.
• Assisted with various aspects of the project's needs including bug management and resolution, current state workflow assessments, assist with integration and script testing, downtime activities/testing.
• Created test plan, test data and conducted manual testing to validate functionality and performed regression testing.
• Designed and implemented complex SQL queries for QA testing and data validation.
• Performed detailed business process assessment of the affected business areas.
• Documented the Artifacts according to the Test plan strategy.
• Scheduled the Internal and External Meetings to get the Artifacts Approved.
• Involved in Testing the Healthcare Portal Web Screens from the Client perspective.
• Involved in Testing the MMIS Power Builder Screens for Pharmacy Projects.
• Perform gap analysis in changing old MMIS and Involved in testing new MMIS.
• Actively verifying the codes into the production environment.
• Tested the RI Healthcare Portal for the new member eligibility, member enrollment, Voluntary and Passive Recipients, Recipient Opt Out screen, Recipient Notice Screen for MMP.
• Worked on POS Claims Testing.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Maintained Requirement Management Document to ensure the project conformed to the project charter.
• Expert in Validating, Verifying, Testing the EDI x12 files.
• Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan.
• Performed GAP analysis as pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process.
• Performed GAP analysis on membership management and claims processing to evaluate the adaptability of the new application with existing processes.
• Used and verified the EDI messages 837. Healthcare encounters claim and coordination of benefits (COB)-Claim payment and remittance advice 835 - Healthcare claim status 276/277, Eligibility for a health plan 270/271.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets, ICD9, ICD10 coding
• Determined eligibility benefits for customers with EDI Health Care Eligibility/Benefit Inquiry (270).
• Tested EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment), 276-277 (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Identified and documented the dependencies between the business processes.
• Responsible for checking NPI and approval of claim payment.
• Support the evaluation of progress and readiness towards performing certain key business functions using the EOHHS - CMS (PCUG) blueprint test scenarios.
• Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams.

Environment: SQL, PL/SQL, XML, UNIX, POS, PES, HTML, Web Client, PowerShell, MS Office, Citrix, MS SharePoint, IWS.

Business System Analyst

Responsibilities:

• Performed GAP analysis on membership management and claims processing to evaluate the adaptability of the new application with existing processes.
• Analyzed “TO BE” scenarios based on the data that are currently required to generate reports.
• Performed detailed business process assessment of the affected business areas.
• Elicited and prioritized requirements through interviews, job shadowing, brainstorming, and questionnaires.
• Identified the key stakeholders and conducted stakeholder interview sessions to determine reports that were impacted due to the migration.
• Maintained Requirement Management Document to ensure the project conformed to the project charter.
• Worked on 837 - Claim and encounters.
• Derived Functional, Non-Functional, Informational Requirements and Business Rules in accordance with the project scope.
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals.
• 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.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Determined eligibility benefits for customers with EDI Health Care Claims inquiry (276).
• 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.
• Conducted a session with business, SME and other parties to gather the requirement for the integration of Facets with the providers and other third parties.
• Authored data flow diagrams, sequence diagrams and business process models that describe how the EDI Health Care Encounter Claim Transaction set (837) is used to submit health care billing information and encounter.
• Conducted surveys, interviews and JAD sessions and translated them into Requirements. Suggested measures and recommendations to improve the current application performance of the system.
• Assisted with various aspects of the project's needs including bug management and resolution, current state workflow assessments, assist with integration and script testing, downtime activities/testing
• Worked with PM to prepare Project charter, Project plans, daily, weekly and monthly team deliverables for each phase, drafting WBS and RBS systematically using MS Project.

Environment: Quality center, MS Project, MS Office suite, SQL, MS SharePoint.

Jr. Business Analyst

Responsibilities:

• Assisted the project manager in the creation of the project charter & vision document during the inception phase of the project
• Performed GAP analysis as pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process
• Understood EMEVS, the NY state's electronic Medicaid eligibility verification system & the Medicaid & Medicare intermediary along with their roles in claim processing
• Produced Activity diagrams with defined swim lanes as part of claims process analysis
• Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming & developing questionnaires
• Involved in the testing of web portal of New MMIS system with encounters Claims.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization
• Worked on the claims and provider modules of the New MMIS system.
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management.
• Perform gap analysis in changing old MMIS and Involved in testing new MMIS
• Owner of the business rules document, which documented the business, rules across different systems.
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio
• Led and managed the User Acceptance Testing (UAT) for the implementation of Facets Extended Enterprise administrative system with emphasis on ensuring that the HIPAA regulation are met across all the modules
• Conducted requirement feasibility analysis with the developers to ensure the project was in scope with the timeline defined in the project plan
• Created test plan, test data and conducted manual testing to validate functionality and performed regression testing
• Clarified to claims personnel the new Affinity payments and Explanation for payments (EOPs) for same claim processing cycle
• Designed and implemented complex 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)

Environment:: Oracle, MS Project, MS Office suite, SQL, SQL Server, Rational Suite, MS SharePoint, HP QC.