SUMMARY:

• Qualified professional with over Six years of extensive experience in the field of Business/Systems Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Experience working with HIPAA ANSI X12 4010A 270/271, 276/277, 834, 835, 837 for institutional, professional, dental and commercial claims, and up-gradation of ANSI 4010 to ANSI 5010
• Experience with SOX, Regulatory Compliance and Controls.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Interviewed SMEs and Stakeholders to get a better understanding of client business processes and gather business requirements.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications
• Knowledge of healthcare standard Health Level Seven (HL7).
• Experienced in preparing Business Process Re-engineering Models
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Expertise in the EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up the infrastructure for a software implementation in a clinic environment.
• Good working knowledge of Claims processing, HIPAA Regulations and 834, 837P, 837I, 837D EDI Transactions for health care industries
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Conducting requirement gathering sessions, feasibility studies and Impact Analysis and organizing the software requirements in a structured way using Rational RequisitePro to track development.
• Interacting regularly with the development team, creative services, database designer, system administrator and the higher management to meet the deadlines of Project milestones.
• Worked in close co-ordination with the testing team in developing test plan and test cases from functional and business requirements.
• Performed UAT and exposure to User Certification Testing (UCT) and Operational Readiness Testing (ORT)
• Expertise in understanding and supporting the client with Project Planning, Project Definition, Requirements Definition, Analysis, Design, Testing, System documentation and user training.
• Used Rational ClearQuest for tracking and prioritizing defects and for enhancements after base lining the requirements.
• Used Rational ClearCase for Version Control of requirement documents.
• Good working knowledge of Claims processing, HIPAA Regulations and 270, 834, 837I, 837D EDI Transactions for health care industries
• Experience in Change Management Process (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Experienced with System Development Methodologies (SDLC), Prototyping, ER Modeling, Functional Hierarchy Diagrams, Data Flow Diagrams, RDBMS, Object Oriented Programming Approach, Design Patterns, UML, Data Warehouse (ETL/OLTP/OLAP), Unix Shell Scripts, Service Oriented Architecture (SOA), SharePoint & BizTalk Messaging.
• Expertise in Procurement and Management Services
• Excellent skills in Project and Performance Management to support Strategic Planning, Goal Setting, Strengthen Accountability, Enhance Decision Making, and Improve Customer Service.
• Experience in implementing Microsoft Office SharePoint 2007.

TECHNICAL SKILLS:

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite (Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Performance Testing Tools: Virtual User Generator, Load Runner

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality CenterPROFESSIONAL EXPERIENCE:

Business System Analyst

Responsibilities

• Assisted in the Project manager in creating and updating the Vision Document, Business case, and the Project Plan to define Objective, Scope and Risks. Also assisted in creating RUP iteration plans and phase plans
• Elicited requirements, and managed Change Configuration to maintain an orderly procedure for managing requirement changes after sign off
• Used the Agile methodology to build the different phases of Software development life cycle. (SDLC)
• Followed AGILE methodology viz. Scrum throughout the project.
• Migration of Dental Operations from legacy system Latron to thin client base system QNXT (TriZetto's Product) with to the Dental business. It also focused on analysis of all Dental data and associated business logics
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health Insurance.
• HIPAA EDI transactions such as 834, 837 (P, D, I) 276, 277, 278.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).
• Interface and back-end testing of web-based Health Benefit Adjudication applications. Adjudication of EDI transactions and submission of manual claims for Pharmacy and Dental.
• Creating and running EDI claims for Pharmacy and Dental heating different functionality of the adjudication system.
• Responsible for creating the Business Requirement Document (BRD), Requirements Traceability Matrix (RTM), Functional Specification, Use Cases, Data Mapping, Gap Analysis and User test plan for a complex migration of Dental Claims data to an insurance Oracle based Star Schema data warehouse
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Analyzed the changes made to different EDI ANSI X12 transactions (834, 837 I and P, 278, 270 and 271) under HIPAA 5010.
• Document step by step Facets configuration steps for Quality Assurance team.
• Elicited functional specifications, conducted feasibility analysis, and performed impact analysis
• Elicited Business Rules and other Non-functional specifications for the new system by interviewing the Subject Matter Experts (Doctors & Nurses) to further understand the business models
• Designed, developed, and implemented innovative & sustainable   Tableau reports. Supported effective rollout of reports, including training collateral
• Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Responsible for creating the Business Requirement Document (BRD), Requirements Traceability Matrix (RTM), Functional Specification, Use Cases, Data Mapping, Gap Analysis and User test plan for a complex migration of Dental Claims data to an insurance Oracle based Star Schema data warehouse.
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
• Responsible for positioning and delivering QlikView projects and cross building applications into new and existing customer base
• Developed gap analysis and risk assessments for the FACETS upgrade project including effects on internally developed extensions and third party software for pricing and contract configuration.
• Gathered requirements from the clients and developed crosswalks for 277/288, 834, 835, 837 P/I claims
• Created Request For Proposal to identify possible vendors and obtained cost and functionality information
• Developed test cases based on the crosswalks and compliance guidelines for 277/288, 834, 835, 837 Professional, Institutional and Dental claims and for 270/271 eligibility benefit inquiry and response
• Supported production batch processing of dental and life insurance claims on a TriZetto Facets platform; created and maintained batch input/output transfer scripts to handle processing of data extracts via FTP and VPN. 
• Reviewed analysis of call center’s achievements of key client goals, ensuring continuous and consistent performance
• Data mapping on Enrollment Module (EDI 834) of FACETS.
• Experience in integrating claims, eligibility, provider and data information using facets. 
• Facilitated requirement-eliciting sessions (JAD sessions) with Subject Matter Experts and other Key Users and documented the requirements in an easy to understand format by both the business and technical personnel
• Constructed Use Cases and Wireframes and translated them into a Functional Requirement Specifications document
• Expertise in iterative approach of AGILE development with all the teams members
• Involved in all phases of Software development life cycle (SDLC) using Agile Scrum methodology.
• Establish documentation for agile methodology for implementation with a very water-fall-centric development team.
• Generated test data using X12 generator for transactions 277/288, 834, 835, 837P/I/D. Conducted Gap Researched and understood the claims adjudication and reimbursement systems based on HIPAA X12 4010 standards.
• Created Online User Guide comprising different scenarios, screenshots, and troubleshooting procedures

Environment: MS Project, MS Excel, MS Word, Rational Rose, Agile, MS PowerPoint, Facets, Tableau, UAT, Oracle 9i, QlikView, Citrix (server), Epic

Business System Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Gathered business Requirements, analyzed data/workflows & performed GAP analysis for Dental Data Migration in compliance to the protocol.
• Created dental claim in 5010 837 D Claims.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837-(I,P, &D), 835 Remittances and others.
• Created extensive PowerPoint presentation describing current Dental Claims Processing and proposed upgrading of process.
• Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 278/278, 820, 834, 271U, 835, 837-(I,P, &D), 835 Remittances and others. Resource for UB04 and CMS1500 billing formats, transaction sets requirements, EDI development and Design, X12 protocols through Version 5010 and Errata; conversion needs and understanding of legacy EDI formats
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Tested the claims processing with EDI transactions (270, 271, 835, 837) in HIPPA and HL7 Environment.
• Analyzed trading partner specifications and created EDI mapping guidelines
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Setup Electronic Dental Claims Adjudication (ErCmcRunCldu) batch for Claims team.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Assisted the database development team in data modeling, data structure and data table layouts required for consolidation of incongruent databases,
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Performed extensive requirement analysis including Data analysis and Gap analysis.
• Defined Functional Test Cases, documented, executed test script in Facets system.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Established a RUP (Rational Unified Process) centric business analysis methodology.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Prepared Business Workflow models that cover "How" business processes are accomplished.
• Upgraded HMO Medicare EDI and reporting.
• Developed test plans with QA team and helped test every scenario using Mercury TestDirector Tool for system testing
• Assigned tasks among development team, monitored and tracked progress of project following Agile methodology.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Performed user acceptance testing on the new TriZetto Facets system prior to the migration of the Dental claims.
• Successfully designed a claims re-pricing system (a.k.a National Dental Solution) that re-prices dental claims with business associate, Dental Network of America (DNoA) for out-of-network dental providers. Solution includes Facets Provider Import Subsystem (XPF), custom Informatica batch jobs and a Facets XCOM extension.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest

Environment: Requisite Pro, Rational Rose, Agile, HL7Interfaces, UNIX, PL/SQL, HTML, MS Office, MS Visio, EDI, UML.

Business Systems Analyst

Responsibilities

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Performed Cost benefit, ROI and ROM studies
• Conducted user interviews and documented business and functional requirements.
• Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Upgraded HMO Medicare EDI and reporting.
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintain ace), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).
• Completed the documentation of Claims Scenario’s for the source system
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Trouble shooted file transmission problems and assisted customers with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (837P, 837I, 837D, 270/271).
• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Prepared for GAP Analysis; identified and documented improving areas to meet capital requirement regulations.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering
• Designed High level design, for New process, integrating with legacy and Facets
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Involved in Service Oriented Architecture (SOA) of the claims processing system
• Created use case scenarios and documented work flow and business process using Rational Rose
• Involved in project management using MS Project
• Collaborated with External Auditors and documented SOX compliance requirements
• Documented requirements associated change requests with requirements and connected requirements with Use cases.
• Used Test Director, PL/SQL for testing the application.
• Wrote test cases and test scripts for the User Acceptance Testing
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Maintained benchmark controls to policies, company standards and contracts, performed vendor sourcing, pricing and contract negotiation, performed procurement, ensured compliance with service/joint interest contracts.
• Used Rational Clear case for version control
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.
• Queried database using SQL for backend testing
• Used Rational clear quest for defect management

Environment: Windows XP Professional, Oracle9i, MS Access 2000, MS Excel, RUP, UNIX, Oracle Pl/SQL, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.

Systems Analyst

Responsibilities:

• Interacted with business heads to finalize the Business Requirements for the application.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Used the requirement attributes (priority, effort, and risk) as the basis for negotiating the inclusion of the requirement, to manage the scope of the system efficiently.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Managed changing requirements, which included establishing a baseline, keeping track of the history, determining dependencies that are important to trace, tracing relationship between related requirements and maintaining version control.
• Prepared and documented System Requirements and workflows for the Content Management Application tool.
• Responsible for integrating with Facets. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Checked Business Readiness and determined activities of flow.
• Built routing rules, for workflow queues in the Workflow application of Facets to establish supervisor dashboard and workload balancing.
• Developed & executed several Optimized queries in SQL on this data.
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language (PL/SQL).
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Wrote Procedure Manuals and was responsible for continuity preparedness.
• Managed various tests, stored test information, reviewed and analyzed test results.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Helped in writing Training manuals and helped business with the Training on one to one sessions.
• Employed Rational Clear Quest for effective Change Management (Requirements Creep) and bug tracking during the testing lifecycle.

Environment:Rational Rose and Requisite Pro, MS Visio, MS Project, UML, XML, Windows XP, NT/2000, HTML, Vignette Content management Tool, Oracle Pl/SQL, J2EE (JSP1.2), XML, XSL, XSLT, HTML, Oracle 9i.

Business Analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Updated provider tables, diagnosis tables, fee schedules, and service ids contained in Facets back end tables.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Created Process Work flows, Functional Specifications documents and documented system requirements.
• Provide implementation assessment, strategy, and mentoring services for Rational Rose, UML and RUP.
• Interacted with various cross-functional teams on building business use cases, and understanding expenses and revenue stream.
• Working with clients to better understand their needs and present solutions using structured SDLC approach.
• Performed user acceptance and parallel testing for coding, pricing, and benefit builds in Facets.
• Interaction with the developers to report and correct bugs.
• Developed the systems implementation project management plan with milestones and steps from procurement of vendors to project implementation and maintenance.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs. Ensured that critical requirements are not missed.
• Aided management in standardizing web applications by preparing GUI standards and recommending alternatives for incorporation in a phased, iterative manner.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Analysis of new Business Requirements and preparation of the Functional Design Specifications
• Interacted with clients like SPF Securities to finalize their website look and contents.
• Analysis of the new requests specified by the end users for the future releases and discussion with the functional and technical teams.
• Communicated changes to requirements promptly and precisely to all personnel involved.
• Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.
• Analyzed and translated business requirements into system specifications.

Environment: J2EE (JSP 1.1), EJB(2.0), Servlets 2.2, JMS, Java2 (JDK 1.3), STRUTS,JDBC2.0, XML, XSL, XSLT, Rational Rose, PL/SQL, UNIX, HTML, CSS, JavaScript, Websphere4.0,Oracle 8.0, WebSphere Studio Application Developer v5.0, Win2000, Unix(AIX)