SUMMARY:

• Experience with Bluecross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837, 997 for interfaces and images to third party vendor applications
• Experience as an Enterprise/Portfolio Analyst
• Trained the team on JIRA tool for Agile/ Scrum Methodologies.
• Facilitated various meaningful scrum meetings.
• Experience with PBM, claims process and adjudication in the Medicare, Medicaid and Private Insurance Sectors, PPACA (Patient Protection and Affordable Care Act).
• Experience gathering Requirements Matrix and developing project work flows as and when required to ease the understanding of the project needs, features, functional and system requirements.
• Knowledge of project metrics, including gathering, reporting, trend analysis, creation, and metrics
• Extensive experience in developing Mock - ups/Wireframes, conducting Gap, Impact, Cost Benefit, and Risk analysis.
• Followed the Agile methodology, RUP and extreme programming concepts of project development.
• Experience in HIPAA 5010 and 4010 transactions as well as ICD9/ ICD 10.
• Experience with HIPAA compliance and 21 CFR Part 11 code of federal regulation for electronic records and electronic signatures in line with Affordable Care Act (ACA).
• Experience in EDI automated claim adjudication, requiring thorough understanding of claim processing, both front and backend operations like Enrollment, Eligibility verification for members and providers, benefits setup, and backend payment cycle.
• Experience with Trizetto QNXT/Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs and proprietary format files and Reports development.
• Came up with data cleansing strategies with data architects and project leaders and documented the processes.
• Develop/Manage change request, Project Plans, Project Schedule, Communication, Resources, Quality Management for management reporting.
• Manage project scope by assessing requirements changes, determining and conveying impact on budget, time and risk.
• Worked in ETL environment involving Informatica/DataStage and Business Intelligence tools like Cognos, Business Objects.
• Worked with various teams and data-architects to come up with processes in Dev/QA/Prod for extraction, transformation and loading the data into the datamarts.
• Actively involved in developing, executing and managing User Acceptance Testing (UAT) and QA methodology
• Experience executing test cases and doing Ad Hoc Testing, Regression Testing, System Testing, Unit Testing, logging defects and tracking to resolution.

TECHNICAL SKILLS:

Process/Modeling Tool: Software Development Life Cycle (SDLC), VSS, SSIS, Reporting tools Cognos, Crystal Reports, ERP Package Oracle E-Business Suite, SAP, OpenCMS, Business Modelling tools Borland Caliber, IBM Rational Requisite Pro 7.0, Tableau Software, Accuprocess, SmartCapture, ClearCase, ClearQuest, Edifecs Claims processing tool

Methodology: OOAD, UML, RUP, Business Modeling and Data Modeling.

Databases: MS Access, SQL server, Oracle, SAP

Office Tools: MS Office 2007/2005/2003/2000, Word, Excel, PowerPoint, Access

Project Management: MS Project 2003/2000, MS Excel, MS Visio

PROFESSIONAL EXPERIENCE:

Confidential,Chicago, IL

Portfolio Analyst/ Lead Business Analyst

Responsibilities:

• Defined and documented business and non-functional requirements using appropriate documentation techniques to describe statements of the goals, objectives, or needs of a particular stakeholder or group of stakeholders
• As a part of technical team the work comprised of creation of Business Requirements Document, Functional Requirements Document and Technical Requirements Document.
• Worked on consolidating the data elements with acceptable values from different data sources at enterprise level.
• Worked with stakeholders to elicit, analyze, communicate and validate non-functional requirements as related to business processes, policies and information systems.
• Worked on projects like ICD-10 Provider testing and Rapid response implementation and identified root cause and issued tasks and sub Tasks for a faster resolution.
• Supported the front end Provider testing and ensured the claims received were in correct format and ensured a faster and issue less claims processing for the examiners and back end processing.
• Worked on several fast paced Government projects and coordinated with regulatory and compliance teams.
• Worked on Corporate communication projects like Multichannel correspondence, lifetimes newsletters, SharePoint content management systems, SBC, Benefits booklets and contract admin enhancements and created functional and system requirements
• Worked in Agile methodology and created user stories, test stories and trained the team on JIRA tool
• Worked on reporting dashboards for the JIRA tool
• Participated and contributed to the meetings with the development, QA and testing teams and ensured that project plans and test plans are updated and posted on team rooms or share point sites.
• Utilized ALM for updating the test scripts and documenting the test results throughout product lifecycle.
• Mapped data and utilized the system design further ensuring increased level of clarity for the team.
• Provided input to estimates for project management and change management activities through analysis of requirements effort, resources, and technology.
• Worked independently as well as collaborated with a larger group of business analysts, business SMEs and stakeholders.
• Worked on requirements for consolidating data sources, creating search keys, developing metrics for webservices.
• Experience with Medical Management, UM, CM and DM.
• Coordinated with large teams and multiple SMEs.

Environment: claims processing tool JIRA,CA service Desk, MS Office 2007, ALM, Lotus Notes 8.5, Edifecs Transaction Manager, Clarity, Microsoft Visio, MS Project, Rational tools, HP Quality Center

Confidential,Schaumburg, Illinois

Sr Business Analyst

Responsibilities:

• Contributed to the JRP sessions onsite, worked with business users, SMEs and external stakeholders in defining functional requirements. Conducted JAD sessions for offshore development team.
• Worked on the enhancement projects for RXExpress, Home Delivery and ESKER fax.
• Develop/Manage Project Charter, Change Request, Work Breakdown Structure, Project Plans, Project Schedule, Communication, Resources, Dependency, Quality Management, and Monitoring Progress/Budget for management reporting.
• Created several functionalities like combining open orders, restricting filling control substances thereby reducing the overall cost to the company and saving the amount for other areas.
• Worked on several Medicare part D projects and streamlined the processes and queues.
• Worked with Business Solutions Vendors such as Elavon, Implemented echecks, bill me later upgrading the Master drug Database (MDDB) versions for daily, weekly and monthly updates. Utilized the existing Client Hierarchy; Real Time process knowledgebase for building a sound migration plan and create Rationalization (justification) Reports for JAA and JRA sessions.
• Worked on Pulse 3.0, uploaded and generated Development Request and created product change for sending out to the development team.
• Created Weekly status reports for all the documents and enhanced the reporting system for an increased level of clarity for the team and to address the issues on time.
• Managed the project management conformance related Form Submissions and Gaps’ Project Dashboard Entries.
• Examined the unit test plans, and directed the onshore/offshore testing team’s work on user acceptance test cases.

Environment: RxExpress, MS Office 2007, SharePoint, Microsoft Visio, Rational tools, Pulse

Confidential,Detroit,Michigan

Sr. Business Analyst

Responsibilities:

• Analysis of existing processes and performing gap analysis based on results.
• Elicitation of detailed requirements from Stakeholders through interviews and requirement gathering meetings.
• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Conducted HIPAA 4010A1 to 5010 upgrade JAD sessions and documented the outcomes on FACETS platform.
• Responsible for configuring Benefits, Pricing, Security, Authorization, Reference and Control table Requirements as per the Affordable Care Act ( ACA)
• Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
• Facilitating JAD sessions with the Configuration Team and the Project Manager for brainstorming to arrive at best practices for the process of Facets configuration.
• Worked with Business Owners from both Medicare and Commercial lines of business
• Conducted post testing defect analysis, regression testing and working with both the Business and Configuration Teams to identify and define requirements.

Environment: Agile Methodology, Data stage, UML, MS Office (MS Word, MS Project, MS Excel, MS PowerPoint, MS Visio), Tableau, Quality Center Amisys, Facets, QNXT, Edifecs transaction manager

Confidential, Blue Bell, PA

Sr. Business Analyst

Responsibilities:

• Created “As-Is Business Models” to understand the existing claim settlement process flow through interacting with SMEs, Underwriters, Actuaries and Finance Department.
• Worked on the mapping of ICD-9 and ICD-10 codes and assisted QA team in creating ICD-10 implementation Test plans and Test Scenarios.
• Responsible for claims processing, coordination of benefits and pricing process.
• Created and maintained system configuration, tables, and codes which helped translate business policies into high quality, timely and efficient system configuration in order to provide accurate claims payment and reimbursement.
• Worked with the development team to support mainframe applications securing the technical requirements.
• Worked extensively with Medicare and Medicaid Claims for 5010 X12 Transactions.
• Helped in performing Regression Testing to ensure the product integrity and also reviewing Test Specifications, Test cases and performed Manual Testing.
• Coordinated with EPIC Implementation team and provided screen designs for current state and future state for both the provider and payer systems.

Environment: HTML, XML, MS-Project, LoadRunner, Agile method, SharePoint, Contact Center, UML, SQL/PLSQL, SQL Server 2005, Datastage, Rational tools, MS Visio, MS Word, MS Excel, MS PowerPoint, HP QC, EPIC 2012, Tableau .

Confidential, Somerset, NJ

Senior Business Analyst

Responsibilities:

• Utilized the existing Client Hierarchy; Daily Claims Feed schedules, and Real Time process knowledgebase for building a sound migration plan and create Rationalization (justification) Reports for JAA and JRA sessions.
• Areas of responsibility included Foreign Claims, Paper Claims, Benefit Edits (especially Drug Edits and Process Plan Options). Worked on Medicare - Payer reconciliation. Worked on NCPDP D.0 compliance.
• Converted the Functional Requirements (FRs) into Process Flow Diagrams and Wireframes. Reviewed Technical Requirements Document ("TRD") as first intra-gate pass. Conducted the internal SME reviews for TRDs, and UATs.
• Managed the project management conformance related Form Submissions and Gaps’ Project Dashboard Entries. Communicate the change permissions with Change Management team.

Environment: SEP, RxCLAIM, ReCAP, AS400, HP Quality Center 10, Synon, RPG/Cobol, SQL, Mainframe, MS Office 2007, SharePoint

Confidential, Shelton, CT

Senior Business Analyst

Responsibilities:

• Gathered and analyzed requirements and transformed into Business Requirement Documents (BRD)
• Created detailed functional specification document for each functionality (e.g. New Accounts, Product, Service Policy etc for the developers and QA team
• Managed Requirements using Application Lifecycle Management and created Reports for the Cognos developers
• Designed and developed all User stories and UML models

Environment: Seibel, MS Project, MS Word, MS Excel, MS Visio, Agile/ Scrum Methodology

Confidential

Business Development Manager

Responsibilities:

• Effectively implemented cost control methods by restructuring the teams and generated revenue of 10 million INR in by establishing contracts with health systems across India.
• Strengthened company profile and brand image in the market through sustained campaigns.
• Analyzed business potential, conceptualized and executed strategies to drive sales, augment turnover to achieve targets.

Environment: MS Outlook, MS Project, MS Word, MS Excel, MS Visio, Agile Methodology

Confidential

Business Analyst

Responsibilities:

• Came up with methods to reduce risks of releasing new upgrade to the system in production by doing a controlled new feature (upgrades).
• Leading cross-functional project teams with change management, project planning, organizing, directing, controlling, and resource management within matrix environment using SDLC tools, and Agile/Scrum to deliver quality outcomes on schedule within budget align with client’s expectations and business needs.

Environment: MS Outlook, MS Project, MS Word, MS Excel, MS Visio, Agile/Scrum Methodology