SUMMARY:

• 7+ years of experience in System Analysis & Design, Business Requirements Gathering, Process Modeling, UML & Testing in the healthcare domain.
• Expertise in working on EDI transactions: 835/837, 270/271, 276/277, 999 as well as Medicare/Medicaid, Healthcare Reform (PPACA), HIPAA 5010 and ICD - 10 compliance.
• Sound knowledge and experienced in HIPAA, ICD9/10, EDI, HMO, PPO, Medicare, Medicaid, SOX, SOP, RDBMS concepts, SQL Server, HL7, SDLC, CMMI, Six Sigma and RUP
• Extensive work experience using MS Visio, Rational Rose to conduct UML Modeling.
• Hands-on experience in writing complex database queries, stored procedures, and triggers.
• Extensive hands-on experience in different aspects of enterprise software development including integration, web services (SOAP, REST, WSDL, UDDI)
• Strong experience in Claims, Claims Adjudication, enrollment, eligibility verification for members and providers, benefits setup, and backend payment cycle in facets
• Experienced in leading requirement-gathering efforts and analysis for application development projects involving Agile, Rational Unified Process (RUP), and Waterfall processes.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Strong understanding of Data Modeling in data warehouse environment such as star schema and snow flake schema.
• Expertise in the EPIC Medical software application (EMR).
• Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA(Patient Protection and Affordable Care Act), Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
• Experience in developing software using SDLC and Agile/Scrum methodologies.
• Experience working in Medicare and Medicaid projects.
• Implemented Usage of Graphical Design and good knowledge on mobile web Portal.
• Excellent team-player with good & effective communication skills as well as multitasker.
• Performed several levels of testing of the conversion from 4010 to 5010 which included syntax verification, balancing of the segments, situational cases and verification of the loops as per the guidelines of the implementation guides and companion guides.
• Diverse experience in working with QA testing teams, while interacting with business users and gathering user’s requirements to develop necessary Test plans, Test Cases and Test script.
• Experienced in conducing GAP Analysis, Feasibility Analysis and Impact Analysis.
• Experience in assisting technical team in different phases of SDLC such as Design, Development and Quality Assurance.
• Sound knowledge and experience with UNIX (Shell Script).

TECHNICAL SKILLS:

Change Management: Rational Clear Quest, Rational Clear Case.

Testing Tools: Rational Robot, Rational Clear Quest Test Manager, HP Quality Centre, Quick Test Professional, Load Runner, Win Runner.

Languages: Java, C, C++,C#, SQL, PL/SQL, Unix shell scripts

Java/J2EE Technologies: J2EE, JDBC, JSP, Servlets, MVC, Struts 1.1/1.2, Spring, Hibernate, LOG4J, JUNIT, JSF

IDE Tools: Eclipse 2.0/3.0/3.1, Net Beans 4.0/4.1/6.0, IBM-Web Sphere Integrated Developer 6.0, Web Sphere Process Server, Toad, WinSQL, Ultra Edit

Web Technologies: JavaScript, CSS, HTML, DHTML, XML, XSLT, SOAP, SOA

Design Methodologies: Object oriented (OOA/OOD), Client-Server, UML, SDLC, V-shape modelling, BPEL, BPMN MVC, Agile, Waterfall, RUP, UML, Scrum

Databases: Oracle 8i, Oracle 9i, Oracle 10g, MS SQL Server2000, MySQL, DB2

Application/Web Servers: IBM Web sphere 5.x/6.x,Apache Tomcat 5.0/5.5, Jboss, Application Server

PROFESSIONAL EXPERIENCE:

Confidential, McLean, VA

Sr. Business System Analyst

Responsibilities:

• Analysed and resolved more than 450 HICS cases.
• Analysed complex research needed cases including policy ID, policy start/end date, covered individual/member dates, issuer name, monthly premium, monthly APTC, multiple - more than one issue reported (i.e., policy dates and APTC amount) and SLCP - refers to an issue with the second lowest cost silver plan (column B of the 1095a form)
• Developed User Stories throughout the Agile Lifecycle as well as created various UML diagrams such as Use Case, Activity and State Chart diagrams with tools like Rational Rose and MS Visio.
• Gathered general information through HICS case i.e. HICS case ID, case narrative, application ID, consumer name, SSN market place moved to MIDAS results with the help of response file through ERR shared drive.
• Gathered the Requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act (PPACA).
• Extensive knowledge on enterprise integration strategies for HIE(Healthcare Information Exchange, CCD (Continuity of Care Document), Medical Summary, PHR(Personal Health Record),third party medical device integration such Welch Allyn, Midmark, Siemens, Phillips, GE Medical, Intellidose, Prenatal.
• Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum, RUP (Rational Unified Process) and Software Testing Life Cycle (STLC).
• Knowledge of Medicaid Information Technology Architecture MITA Service Oriented Architecture (SOA)
• After analysing MIDAS results searched the appropriate HIOS EDBO file through ERR shared drive and gathered relevant information for the appropriate HICS case.
• Participate in Daily Agile Scrum "Stand-up", Biweekly Sprint Planning and Retrospective Sessions and update the team on status of upcoming User Stories.
• Defined frameworks for Operational data system (ODS), Brokerage data warehouse (BDW), Central file distribution (CFD) and Data Quality (DQ) and created functional data requirement (FDR) and Master Test Strategy documents.
• Hands on knowledge of various Health Care standards/requirements like HL7, CCHIT, Meaningful Use & Stimulus Program, HITSP, PQRI, HIE, CQM, DICOM, ISO, IEEE.
• Recommend 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.
• Exposure to HIPAA Compliance requirements and HL7 standards for the exchange, integration, sharing, and retrieval of electronic health information.
• Performed the search in HICS application for other cases related to consumer and if application copied all details into ‘Other HICS Cases’ section in the workbook.
• Knowledge of MMIS (Medicaid Management Information System), MITA ( Medicaid Information Technology Architecture
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Based on the consumer narration, MIDAS results and EDBO results note the appropriate analysis on analysis section of workbook.
• Experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, FACETS 4.5/4.7 system, Claims Processing, Insurance Pricing and Claim Adjudication. Strong Experience in FEP (Federal Employment Program) and CDA (Clinical Development Analytics) . Healthcare Domain Knowledge with SQL knowledge (in Oracle environment) and 5010, ICD-10 experience.
• Update HICS Case Number on Portal with appropriate selections for Case Disposition, Case Status and document the reasoning under Analysts Notes such as denial or approval.
• Updated and save the 1095A Workbook Template for that HICS Case to the ERR Shared Drive.
• Moreover, participated in all phases of testing.
• Mentored business analysts in methodology for defining ICD-10 mapping processes and documenting business requirements. Developed additional processes specifically designed to handle Benefits Administration.
• Participated in changing of 4 digit numeric codes of ICD-9 to Alpha-numeric codes in ICD-10.
• Worked with the technical and development team to resolve and identified the issues in timely manner.
• Reviewed documented training material for accuracy and assisted in end user training along with PII/PHI training and trained nearly 150 new EDI analysts.
• Achieved the sole purpose of 1095a analysis which includes research complex errors on form 1095-A that consumers report to the Federally Facilitated Marketplace (FFM) and correct those errors if the research indicates that doing so is the proper course of action

Confidential

Business Analyst

Responsibilities:

• Gathering business requirements, documenting them, writing scope documents and use cases.
• Involved in meetings with Business process owners, SME (subject matter experts) and IT professionals for requirements gathering and definition.
• Instrumental role in introducing and enforcing new Scrum methodology in MHS with the Express One methodology, a new approach to requirements gathering, software development life cycle (SDLC) process and software testing life cycle (STLC).
• Working with Medicare operational management to monitor, trend and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Implemented enterprise integration strategies for HIE(Healthcare Information Exchange), CCD (Continuity of Care Document), Medical Summary, PHR( Personal Health Record).
• Experience with various ETL, data warehousing tools and concepts.
• Responsible for integrating with Facets, Designing test scripts for testing of Claims in Development, Integration and production environment.
• Full knowledge of application interoperability configurations and managed the implementation tasks of HIE clinical applications.
• Used claims logging a plurality of navigation choices and the appropriate facet element item count by using facets.
• Worked on MMIS system, HIX, ICD 10 and MITA.
• Maintained and enhanced NextGen Electronic Medical Records (EMR), Electronic Practice Management (EPM), and Imaging Control System (ICS) software
• Defined Functional Test Cases, documented, Executed test script in Facets system
• Experienced with the HL7 data transactions.
• Used data analysis techniques to validate business rules and identify low quality missing data in the existing Amgen enterprise data warehouse (EDW).
• Developed Use Case Diagrams, Activity Diagrams and Functional Diagrams using Visio. Manages workflow, system setup, customizations, system build, HL7 & HIE Implementation support, development of training agendas, on-site training & go live support etc.
• Designed, test, and customized EMR templates, documents and crystal reports
• Performed felid-by-field mapping of interface between parent EMR system and downstream system
• Performed data analysis of prior authorization legacy application, then conducted system/user acceptance testing utilizing use cases/test plans, with smooth implementation.
• Good understanding of MITA and MMIS functional business areas which include claims, providers services, providers enrollment, recipient services etc
• Worked on Claims adjudication, Membership, Eligibility, Prior Authorization, Accumulators, Drug Step edits, PHI and different managed care products like POS, HMO and PPO
• Check test files and production files in Medical Claim Mainframe System for 4010-5010 Step Up Step down Project
• Analysis for making system compliant with HIPAA. Involved in making the Medicare patient profiles being compliant with the HIPAA regulations. Management of patient profile transfer (PPT) reports created by data team by verifying the associated data.
• Worked closely with the project manager, business lead and technical lead to identify, research and escalate issues and risks to the appropriate work stream for resolution\
• Performed business analysis for denial claims to find out the root cause of rejection. Once acknowledged all kick out codes were processed correctly and an explanation report was created and delivered to all key stakeholders
• Understand the overall business model of Medicare Part D products and the MMIS mechanized claims processing and information retrieval system and translate concepts into practice
• Conducted phase planning and requirements gathering session with project team, clinical staff and physicians to customize EMR system.
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Extensively used ETL to load data from XML files, Flat files data also used import data.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 837, and HIPAA EDI Transactions across enterprise.
• Initiated with a comparison report of migration of 4010 to 5010. 270Eligibility, Coverage or Benefit Inquiry, 278 Prior Authorizations.
• Involved in planning and implementing both high-level and detailed system and integration test plans.
• Attended weekly testing status calls to update corporate on our testing progress and address any testing concerns
• Utilized RUP (Rational Unified Process) to create use cases, activity, class diagrams and workflow process diagrams.
• Performed overall Requirements Management and built the Requirements Traceability Matrix.
• Collected requirements to develop traceability matrix and perform root cause analysis.
• Audited and tested CPL in production to ensure benefits are reflected correctly in all downstream systems like Member Portals and Provider Network.
• Prepared materials for gate reviews during project lifecycle; addressed recommendations and concerns from each gate review into the project.
• Created Training manuals and documents. Conducted remote and onsite training sessions with multiple users and testers.
• Validate the benefits with the help of document like highlights and GEI in CPL.
• Creation of new groups with Medicare advantage in CPL for the products HMO-POS and PPO with focused on retirees.

Confidential

Lead Benefit Analyst and Product Admin

Responsibilities:

• Led a team of 10 to create, test, validate and quality audit SBCs on a tight time frame.
• Ensure creation of SBC for a group health plan for a consumer request within seven business days.
• Validation of the benefits and conversion of the detailed benefits into the SBC format
• Interacted with Business users, Sales teams and Technical teams for creating the SBC workflow.
• Managed creation of the SBCs on demand from the Sales/ Consumer portals on tight deadlines.
• Analysed medical products, Rx product and benefit plan design.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Maintained control of SBCs entering SharePoint SBC Repository to ensure quality for the Member and Sales portals.
• Responsible for testing complete claims processing workflows as per business requirements
• Developed work plans, estimates and schedules for multiple concurrent projects.
• Responsible for designing, developing test scenarios, test plans and managing test script execution.
• Involved in testing HIPAA EDI Transactions and mainly focused on 837 and 835.
• Regular bug tracking was done and regression tested before turning over to the SBC repository.
• Took weekly status from team members and updated the client on the status of Benefit SBC inventory.
• Lead bug triage meetings to resolve issues that involved creation of test scripts/results.
• Involved in transformation of public sector accounts and national accounts to CPL.

Confidential, Tallahassee, FL

Business facets Analyst

Responsibilities:

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements.
• Conducted functional requirement reviews and walkthroughs with the designers, developers, and stakeholders.
• Involved in Requirement Scoping and analyzing high priority requirement for implementation.
• Captured BRD,FSD and developed process flows using MS Visio for PPACA
• Conducted sign-off meetings with IT teams to lock down the requirements.
• Conducted JAD sessions to allow different stakeholders to communicate their perspectives with each other, resolve any issues and come to an agreement quickly.
• Experience with Facets 4.71, Inbound & Outbound interfaces, EDI configuration, and data mapping using ANSI X12 4010 and 5010 (834,835,837) .
• Hands-on experience with claims adjudication tools: MMIS and Facets
• Worked on MITA to upgrade the existing MMIS and also conducted mapping for EDI transactions
• Involved profoundly in the GAP Analysis of the transition from HIPAA 4010 to 5010(EDI 835 and 837) focusing on how current transactions and system was going to be effected by the new 5010 compliance.
• Used MECT (Medicaid Enterprise Certification Toolkit) to conduct operations
• Performed Data mapping and data translation in HL7
• Worked on daily basis with lead Data Warehouse developers to evaluate impact on current implementation, redesign of all ETL logic.
• Responsible for mapping of ICD9 to ICD10 and also did testing for 270/271, 837I/P/D, 835R transactions to migrate to 5010
• Lead the impact analysis, scope lockdown, and requirements gathering phases of the company's transition from ICD-9 to ICD-10.
• Created mapping documents and also updated Companion Guides for 278, 270/271,276/277,837I.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding.
• Facets Product Configuration of new products and components including research, testing and trouble shooting in FACETs.
• Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Coordinated with Project Managers to resolve risk issues and ensure compliance of Security System related to the HIPAA.
• Performed System testing, Regression testing and UAT for several claim types and test scenarios.
• Compared and validated 5010 system test results with 4010 results for the same test scenarios.
• Conducted requirement gathering sessions with the purpose of creating and defining the Business Requirement Document (BRD) and the Functional Requirement Document (FRD) using Rational Requisite Pro.
• 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.
• Created BRD for new MMIS system and conducted data mapping as well as developed Use Cases/Activity Diagrams.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Worked effectively with physicians, nurses, and engineers to solve problems related to EMR, EPM, and ICS to make software more user-friendly to staff and doctors
• Knowledge and implementation experience of Quality Assurance, Testing Principles, and Configuration and Change Management Disciplines.
• Involved with the Quality Assurance Team to develop Test plan and drive Test Cases.
• Also developed a (UAT) User Acceptance Testing plan to guide a select group of key end-users in testing the user interface and functionality of the application.

Environment: HTML, Rational Rose, Rational Requisite Pro, UML, XML, XSLT, MS Project, Agile, MS Visio, MS Office Suite,, Axis, Windows XP, Unix, HIPAA, Outlook, Test Director, Ultra Edit, JBoss, TOAD, WinSCP

Confidential, Denver, CO

Business Analyst

Responsibilities:

• Involved in Business Analysis for Inbound and Outbound Transactions.
• Performed gap analysis between partner specs and internal system requirements by matching HIPAA 4010 to 5010 implementation techniques.
• Tested HIPAA Transactions and Code Sets Standards such as 837/835, 270/271, 276/277 transactions.
• Captured HLR/ BRD for Health Care Reform project in compliance with the reform needs
• Created maps & layouts for HIPAA as imposed during Electronic Data Interchange (EDI)
• Gather requirements and estimate effort for HL7 interfaces
• Worked on ICD 10 Request for Proposal analysis as well as conducted detailed GAP analysis
• Converted X12 data to XML (using DI) and verify the data by performing schema validations.
• Created Use Case Diagrams and Test Cases for federal employee program.
• Performed Data mapping and data translation in HL7
• Conducted detailed mapping for 4010-5010 as well as ICD9-ICD10 conversions.
• Documented Impact Analysis for 5010 compliance and ICD 10 compliance projects encapsulating effects on different systems and mitigation plan development.
• Created Logical/physical Data Model in ERwin and have worked on loading the tables in the Data Warehouse
• Build, test and Deploy HL7 interfaces on Neon and Seebeyond Datagate interface engines
• Gathered and documented doctor company's business requirements and developed, entered and verified test cases.
• Rendered X12 Syntax Integrated Testing, Balancing Testing, Code Testing, Specialty Testing and Trading Partner Specific Testing when environment is upgraded.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports
• Extensively involved in testing Trizetto Facets and mainly involved in Enrollment and Eligibility modules.
• Performed re-testing in order to verify resolution of defects.
• Collaborated with project team, project leads, and project managers and fostered with them to review plans, systems testing and overall testing of software.
• Provided support during the integration and UAT as well as created User-Manuals.

Environment: NPS, EDIFECS, Requisite Pro, Rational Rose, XML, Agile, Clear Case MS Office, MS-Visio, XML, Java, TOAD, HP Quality Centre, MS Project, SOA.

Confidential, Southfield, MI

Business Analyst

Responsibilities:

• Performed SWOT and Gap analysis for the new functionality requirements
• Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Good knowledge on different modules within healthcare ( Membership, billing, enrollment, claims, capitation, providers ).
• Responsible for checking member eligibility, provider enrolment, member enrolment for Medicaid and Medicare claims.
• Captured user-stories as well as grouped/prioritized them
• Hosted the application online using Microsoft share point excluding some functionality those were developed to use by employees only.
• Provide on-call production support for HL7 interfaces on Seebeyond e*gate and Sybase eBiz Impact.
• Organized meetings and led JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met.
• Analyze and design solutions for issues raised by business teams in the areas of Enrollment (accumulators), Claims(Hospital and Medical), Customer Service and Billing applications in Facets.
• Performing Impact analysis for readiness of ICD-10 conversion.
• Worked on daily basis with the main frame team and lead data warehouse developers to evaluate impact on current implementation.
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Member of the patient information reporting project team for analyzing and designing responsible for analyzing and designing a system that would improve reporting of patient data especially with relation to Medicare population.
• Worked on customization screens/reports related to Member, Enrollments, and Providers in FACETS .
• Working with project business analysis to exchange ideas on how front-end functional requirements will align with HL7 interface requirements
• Responsible for checking NPI and approval of claim payment.
• Conducted JAD sessions and Data modelling using UML.
• Worked on Lotus notes for getting feedback, web based requests and bill approval.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.

Environment: J2EE, JavaScript, CSS, MS Office Tools, Windows XP, MS Project, Agile, RequisitePro, Rational Rose, Clear Case, MS PowerPoint, MS-SharePoint, MS-Word, MS-Excel, Business Objects, XML, XSLT, Oracle, SQL Server