SUMMARY:

• A result oriented individual with over 8 years of diversified experience in Healthcare, Medicare and Pharmaceuticals industry.
• Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.
• Expertise in translating user requirements into technical specifications and mapping the process design, work flows for SDLC with documenting and managing business requirements.
• Possess excellent organizational, interpersonal, communication and documentation skills with good process management skills along with a remarkable ability to gather requirements to bring out quality product.
• Experienced working with multiple teams and coordinated with them to do various releases. Involved in forward mapping from ICD 9 to ICD10 and backward mapping from ICD10 to ICD9 using General Equivalence Mappings (GEM).
• Strong understanding and working knowledge of MMIS subsystems like Claims, Pre - Admission Screening, EDI, TPI.
• Experienced with ICD09 and ICD10 systems.
• Requirement gathering through interviews, workshops, JAD sessions with clients, developers and QA Analysts and referring to existing system documentation and procedures.
• Experience in developing of web-based applications
• Worked with MEDICARE, MEDICAID and FACETS upgrade from 4.7 to 5.01 claims systems.
• Extensively worked with different X12 Hierarchical Levels (HL structures) in various inbound claim/inquiry-response transactions (837 P/I/D, 270/271, 276/277).
• Experience with Business Objects to test Reports.
• Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets
• Gathered requirements to check HIPPA- eligible & participation check for individual coverage.
• Strong understanding of HIPAA Transactions & Code Sets Standards like (820- Premium Payment for enrolled health plan members, 834- Enrolment /Dis-enrolment to a health plan, 835, 837.etc.)
• Possess strong analytical and problem solving skills with the ability to adapt to a new environment and meet stringent deadlines.
• Ability to successfully manage multiple deadlines and multiple projects effectively through a combination of business and technical skills.
• Expertise in translating user requirements into technical specifications and mapping the process design, work flows for SDLC with documenting and managing business requirements.
• Involved in creating test scripts and test data files for the HIPAA transaction based on the ANSI X12N HIPAA standards
• Well versed Facets, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Professional expertise in MS Office, MS Access, MS SharePoint and MS Project.
• Have gathered requirements in compliance with HIPAA, Knowledge of HIPAA 4010 and 5010 transaction standards.
• Knowledge and experience with IBM Curam
• Highly motivated worthy team player capable enough to work and lead within a team environment besides being capable to work independently.
• Strong business analysis skills and thorough understanding of software development life cycle.
• Strong ability to understand and document critical data through effective data collection, data analysis and data interpretation.

TECHNICAL SKILLS:

Methodologies: UML, RAD, RUP, JAD, Agile

Requirement Tracking: Rational Requisite Pro, DOORS

Change Management Tools: Rational Clear Quest, Test

Testing Tools: HP Quality Center, QTP, Selenium

Performance Testing Tools: Rational Suite Performance Studio

Operating Systems: MS Windows 7/XPDatabases: SQL Server, Oracle, DB2, Sybase, MS Access

Office Tools: MS Word, Excel, MS Project, MS Outlook

Data warehousing Tools:: Informatica, Data Stage, SSIS

Query tools: TOAD, Db Visualizer, and SQL Query Analyzer

Reporting Tools: Business Objects, Cognos, Crystal Reports, SQL Server Reports (SSRS)

PROFESSIONAL EXPERIENCE:

Confidential, Reston, VA

Business Analyst

Responsibilities:

• Lead and facilitated Requirements reverse walkthrough sessions.
• Used Agile to manage the huge undertaking in one month iterations.
• Converted existing high-level business requirements into detail design UML diagrams used by developers. Testers and data architects to create the eventual application.
• Researched the newly passed laws like the Affordability Care Act to provide inputs for rules to be included in the application in-order to mimic the laws.
• Created Material to be used and replicated by the state as a way to train the employees about the intricacies of the various Eligibility business rules.
• Helped the Dev team to code the Business rules in a JBOSS BRMS system.
• Business rules involved scenarios involving multiple variables having sequential importance in an asynchronous application.
• Conducted initial Train the Trainer activity before the first batch start the cascading training for other personnel.
• Assisted in design efforts for future Executive Project Rvw reporting.
• Helped testing to create test cases for the tech spec created by me.
• Worked with Performance testing team to generate required data set to be used as sample data.
• In different releases, managed variety of reasons one could get their access revoked for. (Like loss of qualification, cost center change, for cause termination and so on….)
• For each there would be their own set of business rules determining the way and time which is allowed by regulatory authorities to revoke the access.
• Test case preparation and consolidation
• Helping team in testing related activities
• Defect management through Quality Center
• Prepared project testing documents testing status template, testing status reports and graphs through Quality Center.
• Update Quality Center scripts, escalates testing issues to project Manager
• Discussions between development, users and other 3rd party team to resolve issues/doubts
• Helping development team in test results documentation and reports creation.
• Working closely with different teams to gather requirements for testing.
• Analyzing test results and log defects.
• Holds project level testing status meeting to review new defects and status of open defects
• Preparation of testing reports from Quality Center as required by the project PM

Confidential, Sacramento, CA

Senior Business Analyst

• Working on the CA-MMIS System Replacement project consisting of the creation of the new Medicaid platform called Medi-Cal.
• Gathering requirements through interviews and JAD sessions with business
• Gathering requirements in compliance with HIPAA.
• Working with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements.
• Following all the phases of the Software Development Life Cycle (SDLC)
• Designing Activity, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate certain selection criteria and filter conditions
• Translating and transferring requirements from Business Need Document (BND) to Business Requirements Document (BRD)
• Creating Test cases and Test plans
• SQL Server query to develop and perform analysis on ASM submission reporting, processing issues and client inquires.
• Support business process audit controls and requirements.
• Contributing 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.
• Creating test plan, test data and conducted manual testing to validate functionality and performing regression testing
• Designing Claims Inquiry screen within the MMIS and executed Testing Scenarios, Cases & Conditions involving User Acceptance testing, Regression, Integration and System testing.
• Analyzes and provides responses to provider and DHCS submitted questions in support of the SLR application
• Participates in the Business Requirements Document (BRD) creation when requested by DHCS
• Gathers requirements using Joint Application Requirements (JAR) sessions in order to collect and define data
• Analyzes business processes and perform needs assessments to align CA-MMIS information technology solutions with DHCS business initiatives
• Interprets DHCS business needs and translate them into CA-MMIS system requirements
• Responsible for the production of the Specific Functional Design (SFD) document during Phase II - System Design phase of the SDLC and working with the Systems Group technical staff to interpret the requirements into technical design
• Provides deliverables within the time frames defined by appropriate personnel and reviewed often enough to ensure time frames and quality standards are met
• Participates in the SLR application testing and release cycle

Confidential, Boston MA

Business System Analyst

• Followed all the phases of the Software Development Life Cycle (SDLC)
• Performed Gap analysis and assessed risks of the project.
• Gathered Requirements through interviews and JAD sessions with business owners
• Analyzed and worked with HIPAA specific EDI transactions for claims, member enrolment, billing transactions. Worked specifically with 837, 835, 834, 270/271, 276/277
• Observed extensive troubleshooting for the failures in mapping systems for outbound claim payment transactions (835).
• Took part in the meeting held for the analysis of migration to HIPAA 5010 from 4010 and migration of ICD9 codes to ICD10.
• Worked directly with internal and external ASM (Alternative Submission Method) stakeholders to develop and implement documented business requirements.
• Participated in development and performed ETL testing for data warehouse application according to functional specifications using Informatica, UNIX scripts, and Oracle PL/SQL and SQL.
• Wrote complex SQL queries to extract and validate the data from s database.
• Experienced with the communication management.
• Gathered requirements in compliance with HIPAA.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements.
• Used in-depth knowledge of Model 204 User language, write programs to meet requirements.
• Analyzed coding problems and de-bug complex user language programs.
• Extensively worked with different X12 Hierarchical Levels (HL structures) in various inbound claim/inquiry-response transactions (837 P/I/D, 270/271, 276/277)
• In-depth understanding of terminologies like 21 CFR Part 11, FDA, Medicaid, Medicare, HIPPA, HL-7.
• Performed System Integration and Regression Testing for the Microsoft BizTalk 2002 applications. These are developed to perform EDI translation from ANSI ASC X12 layout to MMIS (Medicaid Management Information Systems) fixed-width record format
• Experience in Business Process Analysis.
• Translated and transferred requirements from Business Need Document (BND) to Business Requirements Document (BRD)
• Designed Activity, Sequence and Process Flow Diagrams using MS Visio to simplify and elaborate certain selection criteria and filter conditions
• Created Test cases and Test plans
• Supervised unit testing and performed UAT testing
• Performed claims validation of facets application as required
• Handled the tasks of testing and entering data in FACETS4.7 application

Confidential, Tampa, FL

Business System Analyst

• 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 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
• 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
• Participated in the evaluation, redesign and modification of existing program logic (SSIS packages) to support change and improve overall system performance.
• 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
• Designed Claims Inquiry screen within the MMIS and executed Testing Scenarios, Cases & Conditions involving User Acceptance testing, Regression, Integration and System testing.
• 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.
• Owner of the business rules document which documented the business rules across different systems.
• Involved with various aspects of the project's needs such as the logging, tracking, and resolution of issues, current state workflow assessments, assist with integration and script testing, downtime activities/testing
• Created detailed use cases, use case diagrams, and activity diagrams using MS Visio
• 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 testing and data validation using Cognos.
• 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, Ohio

Business Analyst

• Analyzed the System Requirements, Functional requirements and Business Requirement Documents
• Developed Test Cases and Test plans for Reformat and Routing Process for the IMPACT SIIS Application in a scrum environment
• Extensive use of Quality Center for managing project documents, test cases and test reports.
• Worked closely with the developers on review and resolution of issues.
• Performed back end testing by writing SQL queries to review the returned data to ensure that the correct data was retrieved
• Focused on HIPPA Transaction sets such as Claims Submission, Premium
• Payment to health care provider, Billing claims codes, Enrolment and disenrollment Eligibility, and Billing claims.
• Efforts went in accordance with EAI/EDI/HIPAA Compliance.
• Created XML to test messaging systems
• Used Microsoft Team Foundation Server to report and track bugs and generated defect summary reports.
• Tracked the defects using Quality Center and generated defect summary reports
• Identified processes for developing and documenting detailed business requirements. Data was collected from end-users, and analysts.
• Created Use-Cases and Requirements documents to document business needs. Requirements were gathered through interactions and meetings and periodic walkthroughs with loan analysts, credit analysts, Under Writers and other potential users of the application.
• Conducted Use-Case reviews and identified gaps, leading to improvements/enhancements in the same.
• Created and maintained the Requirements Traceability Matrix (RTM). .
• Worked directly with software engineers to ensure clear communications on requirements and defect reports.
• Followed the RUP methodology for the entire SDLC.
• Used the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of the Software Development Life Cycle.
• Interacting with other teams through walkthroughs, teleconferences, meetings, etc. to resolve various issues.
• Validated the scripts to make sure they have been executed correctly and meets the scenario description.
• Worked with different vendors on Call Center Design and Implementation
• Identified strategic plans to present to Senior Management