SUMMARY:

• Sr. Business Analyst with 7 years of hands on experience in business consulting and application development with excellent skills in client interfacing, requirement gathering, user support, problem solving, and documentation.
• Strong understanding of various SDLC methodologies such as RUP, Waterfall and Agile with hands on experience in all of them.
• Knowledge of Health exchanges: off marketplace exchange and on marketplace exchange. Federally Facilitated marketplace, state partnership Marketplace, State based marketplace.
• Proficient in identifying, documenting and analyzing Business Requirements Specifications (BRS), System Design Specifications (SDS) and Software Requirement Specification (SRS).
• Strong working experience in the Data Analysis, Design, Development, Implementation and Testing of Data Warehousing, DataMarts and ODS using Data Conversions, Data Extraction, Data Transformation and Data Loading (ETL).
• Very good understanding of Data Warehousing concepts, Data Analysis, Data Warehouse Architecture and Designing
• Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes, Claims Process, Health information Exchange (HIE), Electronic Health Record (EHR) and Electronic Medical Record (EMR).
• Specialized experience in healthcare insurance domain including Medicare and Medicaid. Profound experience with HIPPA X12 EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim - status), 834(Benefit-enrollment), 835(Payment/remittance advice), 837(Health care claim).
• Experienced in gathering requirements for HIPAA EDI Transactions (837,834, 835,270,271) in various phases of implementation.
• M edi cal Cl aims e xp er ien ce in P ro ces s D o cu m enta tio n, An alysis and I m p le m entati o n in 8 3 5 / 8 3 7 / 8 3 4/ 2 7 0 / 2 7 1 / 2 7 7 / 9 9 7 (X 1 2 Stand ard s) p r o c esse s o f M edi c al Cla i m s Ind u stry fr o m t h e P r o v id er/ P a y er sid e.
• Experience in conversion and mapping of HIPAA X12 4010 codes to X12 5010 codes and ICD 9 codes to ICD 10 codes.
• Strong knowledge of FACETS and actively involved in end-to-end implementation of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
• Proficient in Requirement Engineering Process, including gathering, analyzing, detailing and tracking requirements
• Experience in interacting with stakeholders like business clients, end users, vendors, SDLC team, configuration manager and production team to identify information needs and initiate process change.
• Expertise in creating various artifacts like BRDs, Functional Specs, Used Cases, UML Diagrams, Data Mapping Documents, Test Plans and Test Strategies, pre and post RTMs and Status Weekly Reports etc.
• Strong visual modeling and business process modeling skills using Rational Unified Process (RUP) with tools like Rational Rose, and MS Visio.
• Expertise in using various tools like RequisitePro and Ms Office for requirement gathering, Quality Centre and Clear Quest for Defect Management/Defect Tracking, MS-Visio for UML Diagrams, Ms Outlook, IBM Lotus Notes and SharePoint for information sharing.
• Effectively used various elicitation techniques to gather requirements like JAD sessions, brainstorming, prototyping, one and one sessions, workshops, surveys, interviews and conferences.
• Hands on experience in the complete Quality Assurance (QA) life cycle from Requirements Gathering and Documentations to developing Test Plan, Test Cases, Traceability matrices and conducting User Acceptance Testing (UAT) for QA Testing.
• Experienced in writing SQL queries to extract data using complex inner joins, outer joins, constraints etc.
• Worked with PMO to review time line and schedule for the implementation and discussing the milestone.
• Excellent analytical, organizational, communication and documentation skills along with good process management skill to gather requirements to bring out the quality product.
• Motivated self-starter, good team member with exceptional team building, leadership, and interpersonal skills to resolve issues.

TECHNICAL SKILLS:

Project Methodologies: Rational Unified Process (RUP), Waterfall, Agile, Spiral, SCRUM

Business Modeling Tools: Rational Rose, MS Visio, Rational Clear Case

Requirement Management Tools: Rational Requisite Pro

Defect Tracking Tools: Rational Clear Quest, Quick Test Professional, Quality Center

RDBMS: Oracle, SQL Server, IBM DB2

Languages: Visual Basic, XML

Business Applications: FACETS, MS Access, Excel, Outlook, PowerPoint, Visio and SharePoint

Version Control Systems: Rational Clear Case

Operating System: Windows, UNIX/Linux

PROFESSIONAL EXPERIENCE:

Confidential, San Diego CA

Sr. Business System Analyst

Responsibilities:

• Acted as a primary contact in all the phases of Software Development Life Cycle SDLC, including Quality Assurance Testing, Performance & User Acceptance testing.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/ Medicaid claims processing.
• Worked with the data architecture and data analyst team in designing the model and in creation of the data mapping documents
• Analyzed the impacts of HIPPA 5010 project on inbound 837 claims
• Gathered requirements from the users and analyzed the requirements for RQ System, Facets etc.
• Extensively worked with FACETS Implementation, FACETS Billing, Claim Processing and Subscriber/Member module.
• Used Data warehousing for Data Profiling to examine the data available (Data Analysis) in an existing database
• Performed GAP analysis for ICD-9 and ICD-10 and EDI 5010 X12 Message Structure with the 4010 Structure. Developed End-to-End Business Process Flows for HIPAA 5010 EDI transactions including 834 (Benefit Enrollment and Maintenance), 835 (ERN-Electronic Remittance Notification) and 837 (Claims Submission) Transactions.
• Worked in the analysis of the ICD 9 - ICD 10 codes conversion Project using GEM (general Equivalence mapping) processes and concepts. Worked in a project involving Miami Systems to create Drug Cards and created Test files to be sent to drug card vendors for approval.
• Involved in end-to-end testing of Facets Billing, Claim Processing and Subscriber/Member module.
• Maintaining knowledge of Medicare and Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations
• 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.
• Worked on a Paid without prejudice project for various States. Performed UAT tests using the (MORAE) Usability Testing Tool using the Observer and the Manager Mode.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence
• Experience in writing SQL queries, Stored Procedures and Triggers.
• Worked extensively with Tableau and MS Excel for the generating of reports.
• Responsible for architecting integrated HIPAA, Medicare solutions, and Facets EDI 834.
• Worked with FACETS, eBilling and EDI HIPAA Claims(837/835/834) processing .
• Analyzed results and EDI ANSI X12 file mapping and reported on standard analysis spreadsheet. Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts. Acted as a liaison between client and payer/intermediary.
• Developed test Scripts using Quality Center and coordinated with developers to quickly resolve the defects associated with them.
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Worked with SSIS for data transformation and defining To-Be processes.
• Experience in Data Validation, Data Modeling, Data Flows, Data Profiling, Data Mining, Data Quality, Data Integration, Data Verification, and Data loading
• Developed several detail and summary reports including line and pie charts, trend analysis reports and sub-reports according to business requirements using SQL Server Reporting Services (SSRS).
• Performed extensive task which include Data Quality Analysis, Data lineage and Data Standardization data structures, data base design, data warehouses, business intelligence/analytic tools, SQL, ETL tools, and data integration methods
• Created source table definitions in the Data Stage Repository by studying the data sources.
• Developed Database packages, procedures, functions, triggers using SQL.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables.
• Conducted JAD sessions with the management, users and other stakeholders for open and pending issues to develop specifications. Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions to test the performance of the application from various dimensions.
• Helped create the 'Business Glossary' to facilitate efficient understanding of the business process amongst the other teams. Assisted in creation of the Functional Design Document from the Business Requirements Document which was used as the reference by the development team while preparing the design and held the responsibility of the required data setup for unit testing.
• Validate transaction records using SQL queries.
• Extracted data from Teradata and Oracle and created pivot tables in Excel
• Developed new reports using Business Objects/Crystal Enterprises on SQL Server, Oracle and Teradata databases utilizing T-SQL and DTS, focusing on data verification and query performance.
• Interpret and analyze data to determine appropriate configuration changes
• Worked extensively in the executing of SQL queries on the database to verify data integrity.

Environment: IDX, MS Visio, Word, Excel, PowerPoint, CMMI, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, Oracle, J2EE technology.

Business System Analyst

Responsibilities:

• Performed GAP analysis as pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process
• Responsible for Documentation in each phase of RUP Methodology, Risk Assessment, and Validation & Verification process.
• Developed Test Plans and Test Cases to test the GUI and workflow for Quality Assurance.
• Used Quality Center to plan tests, manages test assets, create and run manual and external scripts to check GUI and functional features of the AUT
• Involved with requirement gathering and analysis for the data marts focusing on data analysis, data quality, data mapping between ODS, staging tables and data warehouses/data
• Experienced in data warehouses and data marts for business intelligence reporting and data mining along with developing and documenting process flows for business processes.
• Involved in developing and maintaining Test Matrix and Traceability Matrix, and performing Gap Analysis.
• Maintaining knowledge of Medicare and Medicaid rules and regulations and evaluating the impact of proposed changes in rules and regulations.
• Created Process Work Flows and responsible for preparing Functional Requirement Specifications Involved in gathering and prioritizing requirements using 1 to 1 interviews, job shadowing, brainstorming & developing questionnaires
• Performed extensive task which include Data Quality Analysis, Data lineage and Data Standardization data structures, data base design, data warehouses, business intelligence/analytic tools, SQL, ETL tools, and data integration methods
• Prepared test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, data dictionary and data analysis.
• Develop, design & implement department plan to configure new Facets integrated processing system, to include but not limited to, workflow, management oversight and performance analysis.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization
• Used 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) and 820) standards
• 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
• Involved in Up-gradation of HIPAA X12 4010 transactions to HIPAA X12 5010 and ICD-9-CM to ICD-10.
• Full knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups, and Providers. Worked on ICD 9 codes and gathered future requirements based on ICD 10 codes. Managed creation of sample mappings for the conversion of EDI X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Participated in changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Involved in identifying and studying the ACES and Facets system data and field-by-field analysis of Facets system for the attribute mapping purpose.
• Analyzed EDI X12 - 837I/P, 835 and 834 transactions consistency related to providers, payers, subscribers and other related entities
• Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage
• Owner of the business rules document, which documented the business rules across different systems.
• 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
• 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.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Executed advanced level SQL queries to verify data integrity of the databases.
• Involved in the development of Test Plans, Test Cases and Expected Results, and coordinated the tests with the QA team to verify implementation of new features and enhancements.
• Performed numerous data extraction requests using SQL scripts to prepare ad hoc reports.
• Performed Data Analysis, Data profiling and Data validation by writing SQL queries using TOAD
• Worked extensively with Tableau and MS Excel for the generating of reports.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Resolved data issues and updates for multiple applications using SQL queries/scripts
• Responsible for unit testing and working with System/Integration testing team in debugging/resolving any issues raised during testing.
• Created Data Flow Diagrams and Process flow diagrams for various load components like FTP Load, SQL Loader Load, ETL process and various other processes that required transformation.
• 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: MS-Project, Visio, MS Word, Rational Rose, clear case, Requisite Pro, Clear Quest, Test Director, HP QTP, Oracle, EC Map, Facets, HIPAA.

Business System Analyst

Responsibilities:

• Reviewed CMS regulations of EGWP and PDP programs and translates regulations into business requirements.
• Conducted numerous JAD sessions with business users, developer and SMEs.
• Attended regular project team meetings and scrum meetings every day.
• Wrote different SDLC documentation: BRDs, FRDs, Process flow diagram, test scenarios on TrOOP, Co-pay calculations, COB, EOB, Plan finder, Retro Changes and PDE creation and PDE reject handling.
• Worked closely with the Enterprise Data Warehouse team and Business Intelligence Architecture team to understand repository objects that support the business requirement and process.
• Used Data warehousing for Data Profiling to examine the data available in an existing database.
• Design, development, implementation and roll-out of Microstrategy Business Intelligence applications
• Prepared several use cases, designed use case diagram and process flow diagram.
• Responsible for providing business owners (BOs) an overview of processes involved in EGWP and PDP programs.
• Worked extensively on Business Requirements, Functional Specification, Data-Integration, Data Mapping, and Data Warehouse access using SQL and Crystal Reports, ETL process, use cases modelling (UML) using MS Office (Word, Excel, Access, Visio) and dashboards
• Extensively worked on Facets, the claim processing tool used in the project.
• Involved in configuration of Facets Subscriber/Member Application group.
• Analyzed the member/eligibility information on claim to that in Facets.
• Performed Data analysis from the data warehouse along with business intelligence solutions delivery team.
• Reviewed existing functional practices and recommends modification to processes or new strategies in meet business requirements.
• Involved in testing and reporting of errors of subsequent builds during the process of development and production.
• Worked with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects.
• Created and executed test plans that improved data warehouse report quality using Word, Excel and Access.
• Created detailed mapping documents and technical specification documents mapping the fields between multiple databases and the reporting data warehouse.
• Align with the BOs for defining test scenarios; workflow (or business process flows) and training processes.
• Reported and updated any issues to SharePoint repository, as necessary.
• Extensively involved in testing Trizetto's Facets and mainly involved in Enrollment and Eligibility modules.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Involved in data mapping for new databases created to support PDP/ EGWP project.
• Helped database architects define the various fields necessary and create database structure.
• Provided QA support in writing test cases.
• Involved in the PDE design session, provided support to development team in PDE creation as well as PDE reject handling process.
• Wrote SQL queries to produce various day- to-day report and for testing purpose.
• Actively participated in CMS audit.

Environment: Agile, IBM AS/400, Facets, MS Office Tools, MS Visio, Share point, UML, COGNOS, Decision Stream

Business Analyst

Responsibilities:

• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance.
• Responsibilities include the -
• Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system
• Completed Data Mapping for Group and detail Product analysis and report writing
• Analysis and Design of the Facets data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Work closely with EDI to ensure accuracy in data transmissions and shared processes.
• Worked on Mapping documentation using the Implementation Guide for EDI HIPAA 834,835,837(D, P, I), 277/278 and other Health Care Transactions.
• Utilized SDLC Methodology to configure and develop process, standards and procedures.
• Experience with Trizetto Facets System especially with the Managed Care Credit policies.
• Conducted JAD sessions with business users and Subject matter expert and stakeholders to define project scope, to identify the business workflows & task analysis and determine whether any current or proposed systems are impacted by the new development efforts.
• Responsible for managing the Data Warehouse and Business Intelligence functions
• Coordinated with various IT teams related to various Facets backend database for Test Data Setup.
• Designed Test Plans, Scripts after analyzing various scenarios/requirements & performed defect tracking using Test Director & Clear Quest.
• Provided Production support and documented System Release/deployment issues.
• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance. Responsibilities include the - Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system
• Completed Data Mapping for Group and detail Product analysis and report writing
• Analysis and Design of the Facets data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Work closely with EDI to ensure accuracy in data transmissions and shared processes.
• Involved in claim adjudication process of facets application

Environment: Facets, EDI, SQL, Mercury Quality Center, Go To Meeting, MS Office Suit