PROFESSIONAL SUMMARY:

• Healthcare Business  System Analyst  with 7 years of experience in the Healthcare Industry on various areas like Claims Processing, Billing, Insurance and Reimbursement, Medicaid and Medicare Services, and Pharmacy Benefits Management. 
• 7 years of consistent experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, System Change Document, Functional Specifications, experienced in writing Use Cases. 
• Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be'/'Go-To' processes.
• Excellent knowledge of standard industry methodologies like Software Development Life Cycle (SDLC), Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP), Agile (SCRUM), CMM (Capability Maturity Models) and Rational Tools used during various phases of RUP.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities. 
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and UML concepts. 
• Experience with TriZetto Facets 4.21/4.31 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Well Familiar with current industry standards, such as HIPAA, SOX, ISO, Six Sigma, and Capability Maturity Model (CMM).
• Experience in Mapping ICD 9 codes with corresponding ICD 10 Diagnosis and Procedure Codes. 
• Worked with different Business Areas like Claims and Enrollment to document proposed ICD 9 - 10 Code changes. 
• Experience in developing and imparting pre and post implementation training, conducting GAP Analysis, User Acceptance Testing (UAT), SWOT Analysis, Cost Benefit Analysis and ROI analysis.
• Good knowledge about 1095-A Form.
• Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the  834  and  820Companion guides. 
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience 
• Expert in compliance with HIPAA 4010 and 5010 standard. 
• Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements. 
• Strong experience with different project methodologies including Agile-Scrum Methodology, Waterfall, Modified-Waterfall, Iterative, Incremental and RUP. 
• Strong Knowledge and experience of  EDI  transactions, ASC X12 Transaction sets:  834  (Benefit Enrollment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters),  820  (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response) 
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams. 
• Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD. 
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department. 
• 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.
• Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases. 
• Defect Management / Bug Fixing - Fully involved in the process of defect identification and resolution using tools like Test Director, Clear Quest, and Quality Center. 
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking 
• Familiar with PMI PMBOK and IIBA BABOK, Experienced in training and mentoring team members with product knowledge and business processes. 
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio. 
• Good knowledge of PPACA ( Patient Protection and Affordable Care Act) and HIX
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills. 
• Professional expertise in MS Office, MS Access and MS Project.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display. 
• Strong Management and Communication Skills, demonstrated proficiency in leading and mentoring individuals to maximize levels of productivity, while forming cohesive team environments.

TECHNICAL SUMMARY:

Operating Systems:  Windows NT/XP/2000. 

Processes/Technologies: Rational Unified Process (RUP), Waterfall, Agile and Use Cases, Business Process Modeling, and Workflow.

Business Modeling Tools: MS Visio, Rational rose, MS Project

Requirement Management: Tools MS Word, SharePoint, MS Excel 

Defect Tracking Tools: SharePoint Defect Tracking Tool, Quality Centre 

Databases: SQL Server, Oracle, MS Access

Project Management: Microsoft Project and Microsoft Office 

Change management tool: Rational Clear Quest.

Configuration Management: Rational Clear Case

Standards & Methodologies: HIPAA, CMM, SDLC, RUP, Waterfall, Iterative, Incremental, Agile-Scrum Methodology, CPT and ICD-9 Coding, ANSI X12 

Quality Assurance Tools: Win Runner, Load Runner, Quick Test Pro, Quality Center, Rational Functional Tester, and MS-Visual Studio Team Server-Test Edition.

Others: MS Outlook, MS Communicator, MS Live Meeting

PROFESSIONAL EXPERIENCE:

Confidential, Nashville, TN

Business System Analyst

Responsibilities: 

• Interacted with stakeholders to get a better understanding of client business processes and gathered requirements. 
• Collaborated with business analysis team members in understanding existing business processes and requirement management process. 
• Analyzed HIPAA 5010 related to 837, 835, 834, 820 transactions and performed gap analysis between the 4010 and 5010 
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and insured that critical requirements were not missed 
• Gathered requirements and prepared functional documents for Facets 4.71 upgrade for the Trizetto's Client.
• Planned the meetings by providing advanced meeting Agendas and previous minutes 
• Kept record of the meeting minutes and action items 
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277, 835, 834, 820 EDI transactions 
• Ensured clear communication via Activity Diagrams, Workflows, Use case Diagrams, Swim lanes 
• Identified the Gaps and conducted GAP analysis 
• Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD 10 such as EDI Claims Intake, Claims Adjudication, Medical Management- Utilization Management, Case management and Provider Reimbursement- Provider Payment 
• Extensively involved in testing Trizetto Facets and mainly involved in Enrollment and Eligibility modules.
• Work on a contract implementing the Patient Protection and Affordable Care Act (PPACA) for the Center for Medicare and Medicaid Services (CMS) - Center for Consumer Information & Insurance Oversight (CCIIO) Exchange Policy & Operations Group, Division of Plan Management, Issuer Oversight Branch for development and implementation of the compliance review oversight process of health plan Issuers/insurers and their Qualified Health Plans (QHPs) offered on the Federally-facilitated Exchange (FFE)/Federally-facilitated Marketplace (FFM). 
• Conducted Product Review on various aspects of the business documents that were submitted by clients, to see the progress of the project. 
• Worked on the consolidation of the Oversight Checklist area based on the Product Review to identify the process of the business and identify the gap to provide feedback to the client. 
• Worked as a secondary lead on Requirement Management, Data Management and System and Acceptance Testing to help the lead of the designated areas to accomplish the task. 
• Prepared Weekly and Monthly Report with the guidance of Project Manager to be submitted to the client. 
• Worked with cross functional teams to support the implementation and integration of the complete stack of the EDIFECS suite of applications
• Managed the project through Gantt chart, specifying the milestones for completion of all major tasks.
• Maintained the Daily Meeting Log to keep track of the Meetings attended and assuring that a Meeting worksheet has been submitted 
• Implemented HIPAA/ EDI X 12 4010/5010 healthcare-related file formats including 834/835, 837, 820, 270/271, 276/ 277, 278, 999 for acknowledgements 
• Designed use cases and activity diagrams for the processes highlighted specifically by the business. 
• Facilitated JADs for requirement walkthrough, identification of nonfunctional requirements from system users and updated business requirements that provided appropriate scope of work for technical team to develop prototype and overall system. 
• Identified and recognized opportunities to resolve problems related to EDI transactions 
• Mapped the test scenarios to business requirements as part of creating traceability matrix 
• Verified the Business Scenarios on new builds to allow extended testing by the QA team 
• Monitor daily EDI activities such as transmission verification, troubleshooting, analysis, problem solving, exception handling, and re-processing as necessary to ensure reliable and successful operations 
• 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
• Ensured that the Project SharePoint site is up-to-date and versioning of the documents are clearly maintained 
• Maintained a high level of documentation in respect to requirement gathering, keeping track of the product evaluation documents and any agenda received from the meeting or any progress status of the project. 
• Recommended controls by identifying, gathering, analyzing and documenting business and functional requirements for EDI applications; writing improved procedures.
• Responsible for customer interface, requirements definition, general and detailed design, testing, maintenance and training programs and managed requirements using Rational Requisite Pro.
• Developed and executed SQL queries to verify the proper insertion, deletion and updates into the data Warehouse supporting tables.

Environment: MS Project, MS Visio, Trizetto Facets, EDI, MS Word, MS Excel, MS PowerPoint, MS SharePoint, JIRA, Windows XP, HIPAA

Confidential, Bronx, NY 

Business System Analyst

Responsibilities: 

• Knowledge of the complete EDI format used in electronic documentation which was part of the knowledge transfer program to the vendors as per the requirements. 
• Performed Gap analysis pertaining to 4010 - 5010 conversion to accommodate the ICD-10-CM and ICD-10-PCS code sets. 
• Participated in company’s largest team responsible for ACA implementation under Govt. Mandates Program including ICD 10 migration and Chapter 224 -Payment reform
• Involved in associating ICD 10 code sets to CPT, HCPCS code sets and modifiers. 
• Assisted with building the EDI 837, 835, 270/271, 276/277, 278, 820 and 834 transactions processing flow from the Trading Partners to the translator. 
• Actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 codes. 
• Gathered User Requirements and Business Requirements to create the Business Requirement Documentation (BRDs), Functional Requirement Documents (FRDs) using MS Word and MS Visio that provided scope of work for technical team to develop prototype and overall system. 
• Prioritized requirements, developed business scenarios to check how the system would work with the roles and processes of the departments, and developed acceptance criteria. 
• Conducted AS-IS and TO-BE analysis and assisted in developing process models and systems integration structure. 
• Developed Use cases, Use case models, Activity models, sequence diagrams and other UMLs to better understand the functioning and desirability of the application. 
• Conducted and facilitated Joint Application Development (JAD) sessions to reduce time spent in moving information between stakeholders and team members. 
• Wrote Test Cases and Test Plans for the related and assigned scripts according to the test strategies defined in the project and testing team guidelines in Quality center. 
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM). 
• Created Business Workflow Diagrams, Activity diagrams using MS Visio, translated high-level business requirements into specifications for TriZetto team and followed change control process
• Worked with risk management team and identified and analyzed different critical areas of business and the risk involved and then modified business processes to reduce risk. 
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying. 
• Conducted business analysis, acted as a liaison between project manager, business users, & IT team, and used MS Office for the documentation.
• Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using rational tools.
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology. Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
• Established RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
• Performed SWOT and Gap analysis for the new functionality requirements by identifying existing technologies, documenting the enhancements to meet the end state requirements. 
• Conducted various types of internal Audits including Financial and other systems audits. 

Environment: MS Office, Quality Center, SQL Server, Facets 4.21, MS Project, Server, MS Visio, Unix, J2ee, Java, XML, Mainframes and Rational ClearQuest, ClearCase, Windows XP

Confidential, Downers Grove, IL 

Business System Analyst

Responsibilities: 

• Perform gap analysis between HIPAA 4010 820 and HIPAA 5010 820 Companion Guides. 
• Perform impact analysis of other enrollment processing systems to determine potential scope/impacts. 
• Performed thorough analysis of the companion guides from each trading partners both Medicaid and Commercial clients and identified the changes that specific clients need. 
• Review with business owners to identify data requirements and business rules based on the changes within the 5010 834 transaction set 
• Map the data according to the client requirement. 
• Provide dual usage processing capabilities to support both the 4010 and 5010 versions of the 834transaction set to accommodate those clients who choose to remain on the 4010 version and for those clients who convert to the 5010. 
• Monitor state communications to determine if states will be moving from proprietary formats to 5010. 
• Prepare Requirement Traceability Matrix, Functional Specification, System Change Documents, Technical Specification Documents, as-is and To-be flows for the entire conversion process. 
• Work with the commercial business owners as well as the state representatives in process of gathering the requirements. 
• Build a brand new translator for accepting the 834 and 820 X12 5010 files and converting into the flat file layout. 
• Worked with Trizetto to resolve the issues identified at analysis state while building the Custom components for Claim life cycle.
• Mapping the new data in 5010 to the translator to make it 5010 compatible. 
• After performing the thorough analysis, design the new translator based on the specific requirement from the commercial and state clients. 
• Tested the new translator to verify and validate if the input data is being translated correctly to the correct positions in the Flat file. 
• Used SQL Queries in Oracle to pull out data from the databases for the data validation and routine report generation.
• Maintained the dual usage functionality in order to receive the 4010 formatted files for the clients who are not ready to switch to 5010 and 5010 formatted files that are willing to switch to 5010. 
• Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, Sequence Diagram, Collaboration Diagram that include Functional and Non-Functional specifications to hand off to development teams.
• Transformed project data requirements into project data models using ERWIN
• Involved in modeling business processes through UML diagrams using Rational Rose.
• Prepared the common as well as the translator specific test plan for testing the new 5010 process flow. 
• Performed System Testing for the X12 formatted data that gets translated to the flat file through translator. 
• Set-up the trading partners for receiving either 997 (Functional Acknowledgement) or 999 (Implementation Acknowledgement) and not both.
• Worked extensively with MS office suite for preparing status reports.

Environment: Windows, Citrix, MS Office, MS Visio, .Net, SharePoint library, SharePoint Defect Tracking Tool.

Confidential, Pleasanton, CA   

Business System Analyst

Responsibilities:

• Gathered requirement and converted in to technical requirement document.
• Helped business leaders understand business requirements and performing gap analysis relative to industry standards and future directions for strategic initiatives.
• Identified, Evaluated and recommend solution alternatives analysis
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed the Gap Analysis to find the existing gap between the HIPAA 4010 and HIPAA 5010 EDI transactions.
• Worked with development organizations to ensure successful implementations of designed solution.
• Prepared, Presented, and collaborate on all required deliverables of the technical team.
• Documented high level technical design to enable the integration and implementation of the solution.
• Responsible for understanding the strategic direction, priorities and needs of business leaders.
• Create and maintain templates, schedules, estimates and models
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter, to meet and exceed HIPAA requirements set forth by the federal government.
• Re-engineering and capturing of EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• Determined cost factor involved in integration process of third party vendors.
• Create and identified USE Case from the business requirement..
• Create and maintained Software Architecture Document and Logical Solution Design.
• Organized JAD Sessions to resolve issues and conflicts, and to arrive at quick agreements regarding the system architecture design.
• Participated in various meetings and discussed enhancement and modification request issues.
• Actively participated in enhancement meetings. Involved in the meeting with Business process owners, SME (subject matter experts) and Marketing Team for Requirements gathering in definition stage.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.
• Used MS Project for status reporting and planning
• Extensive use of Excel, PowerPoint, Visio, and other MS Office products was required.
• Involved in Deep Dive analysis of implementing new functionality in the Cost Estimation Engine.
• Heavily worked with various group to identify their need to determine different level of integration.
• Interacted extensively with the third party vendor and the management teams to understand the requirements and to report the status of the assessment effort to the audience.

Environment: Diamond, Xcelys, MS project, UML, SQL, Lotus Notes, MS Visio, Agile, Windows XP, MS-Office Suite, MS Word, MS Excel, Cognos Report, Share Point.

Confidential, Dublin, OH

Business Analyst

Responsibilities:

• Analyzed Business Requirements, developing tracking and enhancing them into functional requirements using Rational Requisite Pro as a requirements tool.
• User Acceptance Testing (UAT) - Carried out UAT activities associated with each project and presented the results to the Business Stakeholders.
• Worked on HIPAA transaction codes specifically on EDI 837, 835 and 834 to incorporate enhancements to existing efforts on capturing and mapping, member enrollment and eligibility and contribution data respectively received at the Plan level from the State.
• Documented the meeting minutes from the JAD’s and stored the artifacts in the appropriate place holders in PDS and SharePoint for both the teams to review.
• Worked in GAP analysis to understand the difference between both the billing systems and documented the GAPs in GAP analysis spreadsheet.
• Used UML and RUP best practice methodologies along with supporting toolset including Mercury Test Director, Caliber RM and StarTeam for overall development framework
• Documented the business requirements into functional requirements document.
• Gathered the requirements and transformed them into high-level Process-Flow Diagram using PowerPoint.
• Created a task plan for the team identifying the key deliverables and the respective deadlines.
• Created the ETL requirements to load the data into TeraData.
• Analyzed the business requirement as per the HIPAA rules and regulations.
• Involved in preparing Test Plans based on User Requirements Document (URD) and prepared the Test Cases using Test Director/HP Quality Center.
• Assisted end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS(Data Base Management System).
• Created mapping/crosswalk documents for mapping data flow between systems.

Environment: Windows XP Professional, Mercury Test Director, Oracle, MS Access 2000, MS Excel, RUP, Oracle, UML, Rational Rose, Requisite Pro, TOAD, Rational Clear Quest 2002, MS Office suite, MS Visio, Informatica