SUMMARY:

• In depth knowledge of Software Development Life Cycle using various methodologies Agile, Scrum, Waterfall, RUP and associated artifacts.
• Expertise in managing project portfolio, project finance, risk analysis and mitigation, conducting market research, benchmarking, root cause analysis, trend analysis, and tracking using MS Project.
• Communicated with PEGA support team in order to resolve technical issues which hot fix from PEGA systems.
• Expertise in gathering/eliciting business requirements, detailing, converting business requirements to technical requirements using different tools and techniques
• Designed High level design, for New process, integrating with legacy and Facets
• Solid understanding of Membership, Claims Processing (FACETS platform), Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions (837, 834 and 820).
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc.
• Designed and tested processes and vendor integrations supporting membership, medical management, claim adjudication, and accumulator integration.
• Used Microsoft SharePoint as a Web - based Content Management System as well as a Document/Project Management tool
• Experience in visualizing the design of the system using UML diagrams, Activity diagrams, and Web page mock-ups
• Extensive experience in Rx claims processing applications, interfaces and PBM (Pharmacy benefit Management)
• Executed SQL queries and documented them as part of validating the Business Object reports and for testing purposes
• Excellence usage in IBM Curam (HCR and CGIS).
• Excellent Track record in CRM industry with Microsoft Dynamics CRM at application, industry and domain levels.
• Facilitating one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
• Experience in using SQL queries to access database and clear conception about data warehouse
• Good Exposure to PEGA PRPC architecture, Inheritance and Rule Resolution
• Experience in various methodologies including Agile, Scrum, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Clear conception about Medicare, Medicaid and other health insurance plans, MMIS system implementation and upgrade
• Ability to use Six Sigma/lean methodologies combined with data analytic findings for business process improvement. Also used Six sigma tools for analysis activities
• Experience in multi-tasking such as managing numerous simultaneous projects with great attention to detail.
• Provided Microsoft Dynamics CRM Application, industry, domain thought leadership, knowledge transfer, guidance including but not limited to Best practices, dos and don'ts.
• Experience in solution assessment, validation and applying critical thinking for problem solving approach
• Excellent team player with good communication, presentation and interpersonal skills.

TECHNICAL SKILLS:

Programming Languages: C, C++, Java, HTML, XML, PHP, SQL, PL/SQL, Hadoop.

Database: MS Access, Oracle, MS SQL Server, MYSQL

Operating Systems: MS-DOS, Windows, Linux, Apple McIntosh

Software: MS Office Suite (Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Eclipse IDE, Adobe Acrobat, Adobe CQ5, Adobe Fireworks, MS Office FrontPage, Lotus Notes, Clear Quest, Clear Case.

Performance Testing Tools: Quick TestPro (QTP), Virtual User Generator, Load Runner

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

Reporting Tools: Crystal Reports, SQL Server Reports (SSRS)

Testing tools: Requisite Pro, Win runner, QTP, Test Director, Quality Centre, ALM, HTTP Unit, Ascential Test, Confluence.

PROFESSIONAL EXPERIENCE: 

Sr. Business Analyst

Confidential, Bronx, NY

• Participated in gathering User Requirements, developing functional specs and configuration summary documents
• Worked on 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.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Developing Activity, flow, section, class, data model, Agent and other objects in PEGA.
• Configured, customized Microsoft Dynamics CRM 4.0, 2011, 2013 application software multiple times to meet business needs.
• Have good understanding of Curam Business Models and Documentation center.
• Used MS Dynamics CRM SDK, WCF, XRM and LINQ to interact with data from the CRM system
• Performed RCA on denial claims for rejections based on new ICD-10 adjudication.
• Performed impact analysis for readiness of ICD-10 conversion and dual processing to continue run out of ICD-9 claims.
• Revitalized requirement elicitation techniques - conducting user interviews and JAD sessions and managed the requirements using Rational Requisite Pro and Use Case Modeling with all phases of SDLC.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Efficiently Completed configuration requests as assigned, based on approved business requirements.
• Supported Data Migration from legacy system to Dynamics CRM.
• Worked on developing the business requirements and use cases for Facets batch processes.
• Created class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives. .
• Experience working on integration, Data Mapping, XML Facet, And Gap analysis.
• Checked if the Subscriber has active eligibility under NYCDFHP Plan.
• Used Curam framework to drive requirements, process flow documents, and subsequent design estimation. Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Experience with Pega Work List and Workbasket functionalities.
• Worked on EDI transactions: 270, 271, 834, 820, 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.
• Involved in testing the Member Enrollment, Eligibility Enquiry, Eligibility Response, Claim Status Enquiry, Claim Status Response and conversion of Financial Claims. .
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277 (X12 Standards) processes of Medical Claims Industry from the Provider/Payer side.
• Chaired Requirement Gathering Sessions (RGS), Joint Application Development (JAD) sessions, and lead the effort to get Business and System requirements baseline (stakeholder approval).

Environment: Microsoft Visio, Oracle, Microsoft Office Professional (Outlook, Word, Excel, Access, etc.), Microsoft SharePoint, BPMN, UML, RUP, SQL, Cognos, User Stories, ADHOC, DATA MINING, UAT, Scrum.

Sr. Business Analyst

Confidential, Cambridge, MA

• Conducted Q&A sessions with the SME’s, gathered requirements; analyzed and documented the requirements.
• Conducted GAP Analysis to illustrate the differences between use of the IVR System and traditional clinical screening.
• Conducted one on one interviews with Clinicians to understand the process of approving new subject into a Clinical Trial to become a SME on new subject enrollments
• Analyzed business requirements and segregated them into high level and detailed Use Cases, Activity and Sequence Diagrams
• Work with Curam Software V 6.0 to implement eligibility system.
• Conducted weekly review meetings with team to ensure deliverables were met and any changes/concerns were dealt with in a time manner so the overall timeline would not be greatly impacted.
• User pega to import the data from multi tab excel file, validating and loading into screen to mass upload process.
• Hands on experience on Dynamics CRM forms customization using JavaScript and integration of CRM with other web/windows applications.
• Strong experience with Fit Analysis/GAP and End User support.
• Experience with PBM, claims process and adjudication in the Medicare, Medicaid and Private Insurance Sectors, PPACA (Patient Protection and Affordable Care Act).
• Prepared Requirement Traceability Matrix to ensure all the features for the project were captured and mapped as per the requirement in the BRD.
• Coordinated in developing test scenarios, test cases and implemented test plan with QA team.
• Coordinating and working with IBM Curam team on Curam requirements and then verifying the test cases/scenarios for the same.
• Conducted User Acceptance Testing (UAT) with both business user and vendors while documenting the necessary training material.
• Analyzed data to generate information about clients and their attributes, and drafted a data requirement document.
• Prepared Business Workflow models and process diagrams depicting how business processes are accomplished.
• Created Activity Diagrams, Data Flow Diagrams, Use Cases, Business Process flowcharts for the To-Be process.
• Has Got Excelled in Creating the Flow in Microsoft Visio and Creating the Class Structure Pega
• Created detailed workflow diagrams, business flowcharts of existing and proposed systems.
• Actively involved in creating/updating Work Breakdown Structure (WBS), preparing deliverable tasks in the project plan.
• Worked in customizing Microsoft Dynamics Solutions to enhance operational and business processes by building Workflow and Dialogue processes, creating Entities, Attributes, Entity relationships, Views and Forms.
• Involved in feasibility analysis and risk analysis of the project.
• Involved in the development of Mail order system associated to this PBM application
• Facilitated meetings with Subject Matter Experts (SMEs) to create the process requirements, process improvements and to properly explain the development team the flow of future data modules.
• Functioned effortlessly and efficiently between four work streams and its task leads, SMEs, development team, and management group. Actively participated in Joint Meetings with the various teams involved in the development process.
• Installed and configured MS Dynamics CRM system for development and testing, configured server instance, created organizations.
• Helped in designing and implementing deployment process, and thus maintaining the application in post deployment process.

Environment:- Agile (SCRUM), HP Quality Center, MS Office, MS SQL SERVER, JERA.

Business Analyst

Confidential, Philadelphia, PA

• Involved in requirements gathering sessions with Business Analysts and Architects to understand requirements in terms of business change.
• Actively worked on Business requirement analysis and Data analysis.
• Analyzed System Impact including MMIS Tables, Windows, Reports and Interfaces to external entities.
• Got hands on experience on analysis of GAP analysis between current HIPAA 4010 and HIPAA 5010 requirements.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
• Got exposure of IBM mainframe environment for Medicaid Management Information System impact assessment. Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
• Coordinated with process owners / SMEs and project teams to prioritize product backlogs for PEGA agile scrum sprint cycles based on different types of portfolio assets in consideration.
• Involved in assigning the appropriate benefit accumulators and member group ids for corporate and nationals in the genotable and dedmax using claims processing system.
• Performed analysis of current operations with IBM Curam Healthcare Reform Case Management.
• Provided business support for benefit accumulator and claims processing system.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Ensure the UAT test scripts review sessions with business owners to test the application functionality and providing necessary training material.
• Analyzed HIPAA 5010 impact on external Data Warehouse and data warehouse extract process and mapping of MMIS database and data warehouse.
• Escalated Cognos BI related issues to Cognos Alliance support and got them resolved.
• Performed various integrations with external systems by coordinating with the external team members and using the Pega PRPC Connectors and Services
• Reviewed new reporting and BI tools to determine how department can integrate them with current environment.
• Responsible for Gap Analysis in changing old MMIS and Involved in testing new MMIS.
• Gathered all the needed data (table names, column names, field names, notes) from the Windows and Interfaces documents. Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.
• Elicited business requirements and business needs as part of an Agile Scrum team
• Responsible to meet the information demands of business users by delivering timely, accurate, meaningful and standardized data and reporting.
• Documented analysis, observations and recommendations.
• Experience in Forward Mapping and Backward mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).

Environment: MS Office, Agile, Rational Rose, MS VISIO, UML, SQL, Business objectives, XML, HP Quality Center ALM, SharePoint.

Business Analyst

Confidential, Minneapolis, MN

• Conducted Rational Unified Process (RUP) to gather requirements for other insurance companies in order to check
• the outstanding balance from other accounts.
• Knowledge in RUP software Development cycle methodology with four consecutive phases - Inception,
• Elaboration, Construction and Transition.
• Defining the Business Process Model and Data Process Model by Web Page Mock-Ups using MS Visio.
• Developed technical documentation for Root Cause Analysis on customer support issues.
• Knowledgeable in business process analysis (use cases and/or process flows) and (gap analysis) techniques within the CURAM Application Suite.
• Ensuring business requirements and providing as a liaison between the Business needs (business users and sponsor) and the Technical solutions (development and testing staff).
• Ensuring the strict following of HIPAA compliance and providing security to protect patient information.
• Developed Requirement Traceability Matrix, and other training material for business and functional requirements for web based applications.
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system).
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Performed data analysis for ADHOC business requests.
• Trained and guided Users for the newly developed application and ensured quality of the overall Workflow
• Process and provided the training manual.
• Documented workflow and results of analysis for the aging accounts.
• Developed and implemented plans to bring down the Accounts Receivables aging days.
• Assisted in documenting Project Plan, proposal, RFP, evaluation criteria, proposal approval, project scheduling.
• Performed analysis of current operations with IBM Curam Healthcare Reform Case Management.
• Project report, release document and design document.
• Documented and presented every month’s collection reports.
• Analyzed and created various client reports for several financial requirements and needs.
• Used Rational Clear Case for Version Control of requirement documents.

Environment:- RUP, Rational Requisite Pro, UML, User Stories, SQL Server, ADHOC, DATA MINING, Rational Rose, XML, Use Case Documentation, Rational Clear Case.

Business Analyst

Confidential, Tampa, FL

• Prepared logical data model in the form of Business Context diagram to include various entities and attributes in order to facilitate the design of Data model in the form of ER Diagrams.
• Studied current information structures and data models of the current databases to better understand the design of target data source.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Modeled Business requirements into workflows to depict various scenarios of system to request RFI and RFP responses from major vendors.
• Responsible for identifying, documenting and testing the data mapping feeds from several reference data systems, to risk applications
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Intricately involved in Business Process Flow development, Business Process Modeling, and ad hoc Analysis
• Performed detailed comparative analysis of response to RFPs of vendors and Graphically Represented the recommended solutions in PowerPoint to Senior Management
• Prepared and maintain Business Rules Spreadsheets (BRS) identifying Rules, Triggers and corresponding data fields from Legacy to target CRM application.
• Actively interacted with different business groups to perform Gap analysis to identify the deficiencies in the system by comparing the actual objectives with the system objectives desired.
• Prepared Test Cases based on base-lined Requirements Document, prepared Requirements Traceability Matrix and provided Performance Testing Requirements. Worked very closely with the Test team to Test all iterations during the Testing Phase and documented all the defects.
• Facilitated the User Acceptance Testing (UAT) with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
• Prepared training materials in the form of User manuals by preparing step-by-step guide to all screen flows in CMS.
• Assisted in development of User Interfaces and prepared screenshots to get business's buy-in on the requirements.

Environment: Rational Enterprise Suite (Rose, Requisite Pro, Clear Case, Clear Quest), MS Office, Oracle, SQL, Win Runner.