SUMMARY:

• Accomplished, talented and results oriented IT professional with Nine (9 ) years of experience in Business Analysis, Claims processing in Healthcare, Property & Causality organizations.
• Extensive experience in gathering, defining, business requirements (BRD) translating them into technical specifications and functional requirements (FRS).
• Worked on various Insurance areas like Healthcare (Enrollment, Benefits, Claims, Medicare and Medicaid), P&C, Confidential and Sales.
• Experience in analysis, verification, documentation and processing of applications for Claims.
• Worked on integrating legacy systems Business rules to Guidewire for handling policy administration, end - to-end claims processing, billing and payment modules.
• EDI Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/270/271 processes of EDI Medical Claims Industry from the Provider/Payer side.
• Experience with Confidential, sales, and CRM tools such as Eloqua, MS Dynamics and Siebel
• Excellent knowledge of all the phases of the Software Development Life Cycle (SDLC) in various methodologies like SAFE Agile, SCRUM and Waterfall.
• Strong knowledge of change management principles and methodologies.
• Well versed with HIPAA, Facets, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.
• Facilitated and driven JAD and Joint Requirement Planning (JRP) sessions.
• Worked with the business to document and develop formulas for the calculation of premiums.
• Expertise with UML tools, applied for developing Use Case Diagrams, Activity and Sequence diagrams.
• Excellent writing skills in creating Business Use cases and Business Scenarios.
• In-depth knowledge of Rational Unified Process (RUP), risk engineering, data modeling and mapping.
• Functional knowledge of various modules of insurance like channel management, policy servicing, claims management, underwriting, reinsurance and finance.
• Proven experience with HIPAA 4010 and HIPAA 5010 changes in Legacy systems, transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (Claim status), 470 (Benefit codes), 834 (Benefit enrollment), 835 (Payment/remittance advice) and 837(Health care claims).
• Experience in performing Root Cause analysis, Cost Benefit analysis, GAP analysis, ROI Analysis Project planning, Process modeling, RFP, RFI & Data Mapping.
• Solid Understanding in Finance Industry, Investment banking, Retail banking, Commercial banking, Credit Cards and Insurance.
• Experience working on requirement management and defect tracking by using HP ALM, IBM Rational DOORS, and Quality Center.
• Experience in creating Wireframes/UI design and Prototypes using MS Visio, Axure, SnagIt and Paint.
• Responsible to Track, Document, Capture, Manage and Communicate the Requirements using Requirement Traceability Matrix (RTM)
• Proficient in developing Use Case Diagrams, Workflow Maps, Activity diagrams based on UML using Rational Rose and MS Visio.
• Experience in migrating legacy systems to new Web Based and Mobile Applications with major /minor enhancements
• Experience working on Policy documents, Discount Forms and Coverage Selection Rejection Forms.
• Participated in UAT Plans, Procedures, Test Cases, Defect resolution and Prioritization.
• Proficient in writing queries/scripts for data analysis and use Pivot Tables and formulas for data validation.
• Proficient in SQL and PL/SQL Programming for testing database integrity.
• Capable of managing multiple projects simultaneously.
• Strong team building, time management, meeting management skills and a good team player with excellent communication skills for technical and non-technical audiences.
• Organized, goal-oriented, self-starter, and ability to master new technologies; manage multiple tasks while following through from start to completion.

TECHNICAL SKILLS:

Defect tracking: HP ALM/Quality Center, TestDirector, Rational Clear Quest, TRAC, IBM JIRA, Silk Central

Open source tools: SoapUI 2.5/3.0/4.

Claims software tools: TriZetto s Facets 4.51/4.71/4.81, QNXT 4.8/4.7, Diamond and NASCO

Languages: C#, VB.Net, SQL, PL/SQL, T-SQL, XML, Visual Basic

RDBMS: Oracle 11g/10g/9i, SQL Server 2005/2000, MS Access 2007/2003

Data Base: SIEBEL CRM, Dynamics CRM, Oracle DB2

Design methodologies: Agile, Waterfall, SDLC, RUP, UML and Rational Rose

Data Modeling Tools: MS Visio, Erwin

Other tools: SQL*Plus, SQL Developer, SQL Navigator, TOAD, Share point, MEGA

MSOffice: Outlook, Express, Word, Excel and Power point, Office 365

PROFESSIONAL EXPERIENCE:

Confidential, Bloomington, IL

Sr. Business/Functional Analyst

Responsibilities:

• Responsible for translating user needs into system requirements and specifications to meet the project objectives and goals
• Assisted Project Manager in creating RFI & S documentation for evaluation of vendor responses
• Performed GAP analysis which involved understanding the functionalities of old and to-be systems
• Responsible for Interim Process of LNT
• Assisted with co ordination of change request as part of A&D effort and communicate results output to client management and vendor
• Assisted with change request resolution and Escalated issues when appropriate
• Assisted with creation and maintenance of current and future state system views
• Prioritized, maintained user stories and generated status reports in TFS (Team Foundation Server)
• Prioritized features based on customer needs and assisted Product Owner in prioritizing Epics
• Reviewed and provided feedback on functional requirements
• Lead analysis for technical deliverables work
• Responsible for co ordination of delivery of sing off on technical requirements
• Facilitated large business process workshops and data migration/integration JAD sessions
• Participated in Dynamics CRM (D365) functional training workshops
• Worked on data mapping, mapping data fields for inbound leads and fields for contact, opportunity, lead entities etc. in D365
• Performed ad hoc reporting functions for special needs and requests.
• Worked with Confidential consultant and vendor to identify integration touch points and ensure they have been accounted for in the design documents
• Maintained the master list of technical requirements sign off including who reviewed the requirements ad who approve them
• Translated user needs into system requirements and specs to meet the project objectives
• Generated ad hoc reports, analyze data (Pivot Tables) for campaigns and Sales Activities to provide estimates to set future goals
• Performed daily tests in the new system under each Agency role in the existing system
• Responsible for co ordination of performance testing to capture the benchmarks for the existing system
• Responsible for communicating project effort with the area
• Responsible for maintaining Business Analyst document structure, business process documents and various guides to help the department handle the project on SharePoint
• Acquired extensive knowledge of financial products, services & terms during day-to-day tasks, such as - Exchange Traded Derivatives (Futures, Options, Single Stock Equities, Commodities & FX Currency).

Environment: Dynamics 365, Office 365(Excel, Word, Windows, One Note, Outlook, Yammer etc.), MS Visio, SIEBEL CRM, UNIX, Agile (Scrum), finance,Team Foundation Server (TFS), SharePoint, Silk Central, ELOQUA, NAVIGATOR, DB2, MS SQL Oracle, Server, P360, DW

Confidential

Call Center integration

• Performed requirement gathering & analysis by actively soliciting, analyzing customer requirements and prepared the requirements specification document for the application.
• Translated client requirements into Use Cases and process flows to simplify the design
• Analyzed the existing application and understand the logic behind the existing processes.
• Analyzed and prioritized requirements for process improving system usability
• Worked with technical area to resolve issues or concerns with requirements
• Generate monthly reports tracking performance, Confidential and sales activities
• Utilized Sales Work station, Eloqua, SQL to draw insights regarding Confidential and pipeline activity
• Maintained document for tracking risks and issues
• Assisted business managers to identify on-going system improvement opportunities that will maximize business efficiency and effectiveness
• Developed and maintain configuration and functional design documentation
• Reviewed test case and coordinate testing with business representative
• Performed requirements traceability analysis and add test cases to cover gaps.
• Maintained system documentations and make sure they were updated and accurate.
• Assisted in creating monthly/quarterly executive dashboards outlining project KPIs and other metrics
• Developed UAT scenarios and assisted Business partners in executing them
• Solid experience in Finance Industry, Investment banking, Retail banking, Commercial banking, Credit Cards and Insurance.

Environment: ELOQUA, SIEBEL CRM, MS Office, Windows, MS Outlook, MS Excel, SharePoint, Silk Central, NAVIGATOR, One Note, P360, DW, Oracle, UNIX, Adobe Experience Manager (AEM)

Confidential, Bloomington, IL

Sr. Business Systems Analyst

• Worked with stakeholders like underwriting, Actuary and legal to restructure Policy documents, disclosure forms and discount forms based on eligibility.
• Involved in requirement gathering from business users and stakeholders using JAD sessions, brain storming sessions, and analysis.
• Responsible for managing documents on Share point and signoff of the deliverable from Key Stake Holders.
• Involved in creating targeted questionnaires for SMEs to gather requirements.
• Worked on gathering requirements related to state specific coverages and discounts and endorsements.
• Gathered requirements for modules like billing and payment to increase efficiency and provide better customer satisfaction.
• Worked on integrating legacy systems Business rules to web and Mobile enhanced application for handling policy administration, end-to-end claims processing, billing and payment modules
• Accountable for prioritizing Product backlog and Business requirements.
• Responsible for team backlog to ensure the solution addresses priorities and maintain technical integrity.
• Worked with Stakeholders to determine the Business value of each story.
• Worked with team to determine the size of each story.
• Responsible for Product Backlog refinement.
• Created process flows, Use cases, UI design to articulate the product vision.
• Executed deployment and activation defined by the Product Manager.
• Provided Impact analysis during defect prioritization and requirement changes.
• Established short feedback loop between stakeholders/ end users and the team.
• Created Solution Specifications for User Interface Development team.
• Documented various key Business rules based on state exceptions and Laws
• Worked on Gap analysis of detailed level requirements and Solution Specifications.
• Facilitated and lead requirements Walkthrough to various stakeholders and teams.
• Validated technical designs created by IT developers against functional specifications.
• Created UAT scenarios for functional and business checkouts during implementation involving end-to-end process flows and crucial error or alternate flows.
• Provided postproduction support/analysis and assisted in performing User Acceptance (UAT), performance testing and validated test plans. Acquired extensive knowledge of financial products, services & terms during day-to-day tasks, such as - Exchange Traded Derivatives (Futures, Options, Single Stock Equities, Commodities & FX Currency).

Environment: TRAC, Lotus Notes, MEGA, Agile (Scrum), Windows, MS Visio, MS SharePoint, JRF (JDT), ALM/Quality Center, MS Office, Test Link, TIMS, UNIX, HP Service Manager, finance,Java, Axure, J2EE Cloud Management Portal, Jenkins, Version One, WinSQL, and Windows XP.

Confidential

• Performed special assignments (e.g., work with Business Partners on framing-out a new business concept for the company).
• Coordinated with different lines of business -Property and Casualty, Auto, General Liability, Umbrella.
• Served as a liaison between various stakeholders and departments across the region and in the corporate office.
• Analyzed data from various reports and tools, identified issues, and develop recommendations.
• Created presentations, business documents and business proposals.
• Created document of understanding (DOU) for third party vendors and outsourcing project work.
• Worked on putting a standard benchmark across the project for structuring documentation of Business Rules and Requirements.
• Worked with Quality team to set a standard approach for writing Business Rules and requirements.
• Reviewed Business Rules and requirements according to the quality benchmark.
• Created Functional Requirement Document (FRD) and Use Cases to document business requirement in a High level and detailed level requirement.
• Created Process Flow diagrams which helped in understanding and achieving the Business Objectives.
• Used ALM/Quality Center for test plan execution and defect tracking.
• Created process flow diagrams using Microsoft Visio tool.
• Participated in finding Gap in requirements and discussing with respective process team.
• Prepared stories for enhancement and change on the screens in the quote flow and purchase flow.
• Worked with business partners to accomplish best user experience for various businesses need.
• Worked on requirement and test case migration in to Test Link tool.
• Became a part of skill management and training team.
• Created Procedure and Mapping document for Confidential effort.
• Created manual test plans from the business requirements and stored them in Quality Center. Executed the manual test cases, prepare the execution report and Test Sign report.
• Identified, evaluated, and tracked defects. Worked with the mobile application owners until issues were resolved.
• Worked as team lead across IT groups on project change requests.
• Performed data mapping tasks related to allowed values.

Environment: MS Visio, TRAC, Lotus Notes, MEGA, Agile (Scrum), MS SharePoint, JRF (JDT), Manual Testing, ALM/Quality Center, MS Office, Test Link, Java, J2EE, Jenkins, Cloud Management Portal, Version One, WinSQL, Windows XP.

Confidential, Bloomington, IL

Sr. Business Analyst

• Worked with stakeholders to understand the business process and to identify document key business requirements, data elements.
• Provided subject matter expert in all Health Claims to assist in determining requirements for projects.
• Development of health business process repository, and process to support ongoing maintenance thereof post-project implementation.
• Involved in effort to developing a solution framework for back-end claim processing, which will allow Health Claims to interact with the ICP layer and the customer.
• Created SQL Scripts, used Excel functions to generate spreadsheets and Pivot Tables to validate claims data.
• Coordinate and assist in the creation of end user training materials for the Life Health Claims system including tip sheets, quick reference guides, short videos, and eLearning modules, Job aids.
• Played a key role in interacting with all necessary stakeholders to define functional requirements relative to Life Health Claims System (LHCS) system.
• Validated and compared the Claims generated through E2E process with the claims from the existing system in backend executing SQL queries and comparison tool.
• Involved in complete System Testing to prepare LHCS to move into ICP Release and Implementation Testing
• Analysis of business requirements and system requirements of the client and also for Property and Casualty (P&C) modules.
• Defined system scope and objectives of business requirements, including documentation of requirements (i.e. Business stories, use cases) and translated them into (TRS) system requirement specifications.
• Involved in successful signoff of Business stories by identifying and documenting them.
• Drafted key templates for Prioritizing MDL items for CAB releases.
• Involved in generating test cases for Property and Casualty (P&C) insurances for different levels of business.
• Collaborate with work initiation team to develop documentation such as business case proposals, business case template and project charters.
• Gathered Business Requirements, analyzed data/workflows, defined the scope, and performed GAP analysis.
• Collaborate with Customer Experience Monitoring (CEM) identify customer experience impacts, industry trends and competitor analysis.
• Involved with Business Architects to identify Business Events, Date elements, Requirements.
• Communicate status and BDD recommendation to team lead and other core team members to ensure recommendation aligns with target architecture.
• Created ‘Business Glossary’ to facilitate efficient understanding of the Business process
• Involved in Performance Measurement to develop measurable indicators that can be systematically tracked to assess progress made in achieving predetermined goals.
• Collaborate with legal counsel to gather legal input to validate compliance of the application.
• Coordinated with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Functional Requirement Specification.
• Involved in designing and developing Data-Flow diagrams, E-R diagrams, logical and physical database design.
• Analyze business requirements and segregated them into Use Case Diagrams, Activity Diagrams, Sequence Diagrams, thus defining the Data Process Models using Visio.
• Provided business support in integration test deployments and systems test deployments.
• Served as a liaison between systems and business partners from other departments for business related issues.
• Assisted development team to translate requirements into technical specifications.
• Worked as a key liaison between DEV team and testing team to resolve defects.
• Involved in drafting Use cases, Business scenarios.
• Prepared Business Continuity Plan and Disaster Recovery Plans for End users.
• Designed mockup and wireframes to communicate visual data flow to the end users.
• Responsible for designing, developing test plans use cases and executing test scripts.
• Exposure to Client/Server, Web and Mobile Application developmental tools and Software development and design.
• Involved in reviewing test plans and test cases and ensuring test cases reflect user needs.
• Responsible for conducting user training and user acceptance testing (UAT) to ensure and verify system is designed according to user needs.
• Participated in Acceptance Test Drive Development (ATDD), agile project development methodology.
• Conducted review sessions on regular basis with QA and development teams for preparing status, delivery report and accountability reporting.
• Helped manage risk analysis and mitigation plans, status reports, and client presentations; prepared business process models, defined milestone deliverables, and established critical success factors.
• Performed Business checkouts after key deployments in various environments.
• Worked extensively on dataflow and workflow diagrams, with knowledge of Business Process Model and Notation (BPMN), MEGA to define Enterprise Architecture (EA).
• Worked on mapping State Farm business requirements with FINEOS 7.2 (third party tool) out of box systems functionalities.
• Delivered business processes that guided high-level resource decisions
• Help DC4 achieve repeatable success by supplying critical State Farm knowledge and context.
• Offer expertise as processes and procedures are defined to enable and mature Change Management across all lifecycle phases in Claims.
• Participate in unit, regression and User Acceptance Testing (UAT) & communicating bugs to technical staff.
• Performed GAP Analysis between various Business Requirements and Functional requirements.

Environment: FINEOS 7.2, Management Console, Test Link, Quality Center10.0, Manual testing, Agile (Scrum), EDI X12 5010, ICD-10, Oracle 10g, SQL, TOAD, IBM data studio, HTML, Java, J2EE, Spring, AJAX, IBM Web Sphere, XML, MS SharePoint, UNIX, Windows XP and Lotus Notes.

Confidential, St. Louis, MO

EDI Business Analyst

• Reviewed technical documentation to understand the Business logic and technical aspects system.
• Gathering requirements from SME’s and Stakeholders in order to get a better understanding of client business processes.
• Understood the existing environment and created Process flow diagrams for the new system.
• Developed test plans, status report for the management review for complete end-to-end testing for SOA.
• Responsible Forward Mapping and Backward Mapping analysis of ICD-9 & ICD-10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Worked on agile methodology using Scrum.
• A rticulated Business Requirements from User Interviews and then converted requirements to Business Requirement Documents (BRD) and System Requirement Specifications (SRS).
• Participated in JAD sessions for requirement gathering, analysis and design.
• Created transaction sets and mappings in various ANSI X12 EDI formats like X12 837, X12 835 (Remittance Advice), X12 834, X12 270/271, X12 276/277 and X12 278.
• Created SQL scripts to change data and validate service response.
• Involved in maintaining Requirements Traceability Matrix (RTM) using Rational Requisite Pro.
• Involved in GAP analysis of 270 and 271 transactions from EDI X12 4010 to EDI X12 5010.
• Worked to build extensions for Members, Claims, and Billing and enrollment applications.
• Involved in migrating EDI X12 4010 transactions to EDI X12 5010 transactions, level 1 and level2 messages.
• Prepared 837 I&P Claims and validated in claim processing system.
• Responsible for creating and executing test cases.
• Captured all HIPAA-related EDI data in the repository.
• Involved in migration of the legacy system to new web application.
• Created test scenarios for 5010 repositories to ensure maximum test data coverage.
• Created functional dashboards from multiple data outlets and maintained adhoc reports.
• Lead the process modeling effort, involved process modeling training
• Mapping requirements with Test plan in JIRA.
• Responsible for checking the error reports in NASCO model office.
• Interacted with the UAT team to solve issues related to the defects.
• Verified the member validation and provider validation.

Environment: Rational Requisite Pro, MS Visio, JIRA, Agile, Portico, Inspector (Initiate), NASCO Mainframes, Java, J2EE, Struts, IBM Web Sphere, Web services, XML, XML Spy, Oracle 10g, SQL, SQL Developer, MS Office 2007, UNIX and Windows XP.

Confidential, Denver, CO

Business Systems Analyst

• Worked on HIPAA Operating Rules Phase I & Phase II documentation.
• Acted as Scrum team member for the agile core process team applying Scrum principles.
• Gathered Business Requirements through GAP analysis and documented them.
• Performed an in-depth analysis of the system’s organizational structure, services and processes and created As-Is and To-Be process models.
• Prepared Functional specifications by capturing different field length changes, business rules for Federal claim record, Pricing transaction record file layouts, response record changes.
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Interacted with developers and users to analyze the user requirements and functional specifications.
• Utilized RUP to configure and develop process, standards, and procedures.
• Submitted individual and batch Claims like 837 P/I/D.
• Participated in JAD sessions for requirement, feasibility and risk analysis with various stakeholders, including designers, developers, QA and management to identify critical and high risk areas of the application.
• Submitted Exam Entry claims through MMIS.
• Involved in weekly meeting with State employees to get the approval for Requirement
• Involved in testing In-Bound, Out-Bound Transactions (276, 834, 835, 277 and 837) submitted through Data-Exchange gateway.
• Create and maintain metadata and ETL documentation that support business roles and detailed source to target data mappings.
• Involved in processing 837 I/P Healthcare Claims and Health Care Claim Status Request (276).
• Performed Regression and Ad-Hoc testing for the entire application by executing the test scripts, created Test Plan, Test Cases and Test Condition Matrix.
• Developed and executed manual test scripts using test plan and test lab sections of Quality Center for System testing, Integration and Regression testing of the application.
• Interacting with State Employees about the Project Sign off.
• Involved in COFRS Modernization estimation meetings.
• Writing requirements for diagnosis field expanding.
• Responsible for system testing on AWDC project (Adults without Dependent Children Enrollment) into ACC (Accountable Care Collaborative).

Environment: MMIS, RUP, MS Visio, Quality Center, Manual testing, Agile (Scrum), Oracle 9i, SQL, TOAD, EDIFECS, FileZilla, Ultra edit, Java, J2EE, Struts, Hibernate, Java Script, HTML, XML, Web Sphere, MS Office and Windows XP.

Confidential, Cleveland, OH

Jr.Business Analyst

• Worked with Business users and technical lead for gathering requirements and data transaction information.
• Created Questionnaire Document and Work Agenda before the JAD sessions.
• Conducted JAD Sessions periodically with various stakeholders at various phases of the Software Development Life Cycle (SDLC) to discuss open issues and resolve them.
• Created the business process model using MS Visio for SME’s for validation and getting the sign-offs.
• Gathered and analyzed requirements for documenting report which spotlights payer’s performance.
• Identified Claims management workflows, business rules and developed flow charts and activity diagrams.
• Experience working with the EDI transaction sets 835, 837, 270/271, 278
• Involved in the Payer Cycle such as in the enrollment, CCMS memberships, benefits management claims processing, provider servicing, and member servicing and ad-hoc reporting.
• Worked in a team for life Claims processing and was involved in prioritized claims, identified problems, prepared an action plan, implemented the solution, and identified claims outside the benchmark.
• Data conversion of all EDI claims from 4010 ANSI to 5010.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Extracting special Claims to test for MSP (Medicare secondary payer).
• Provided Support services for Centers for Medicare and Medicaid Services (CMS).
• Configured FACETS to adhere to customer’s workflow for claims processing, claims automation and group administration.
• Responsible for queries and extracts of member claims and provider data
• Used FACETS to provide seamless transactions between the provider, members and the plan.
• Involved in writing use cases for medical, pharmacy and vision claims as part of Health Statements.
• Developed improvements to team processes and procedures through change management initiatives
• Developed requirements in designing dashboards for healthcare membership programs
• Documented technical details in the functional including data source, file formats and data mapping.
• Documented System Design Documentation (SDD) describing the systems requirement, operating environment, files and database design, input format, output layout, detailed design.
• Assisted the project manager in writing business cases.
• Used SQL for back end testing and ensured the data is updated accordingly.
• Developed test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.

Environment: Manual testing, Facets, EDI, HIPAA, 4010, 5010, Clear Quest, C#, ASP.Net, ADO.Net, MS SharePoint, SQL Server 2005, T-SQL, XML, Lotus Notes and Windows XP.