SUMMARY:

• Experienced in different SDLC methodologies such as AGILE, RUP, Waterfall.
• Experience in gathering system requirements, defining business processes, UML modeling, sequence diagram and activity diagram.
• Experience in developing project plans, identifying documents, validating requirements and re - engineering process.
• Worked extensively with professional User Interactive (UI) web applications using with the help of HTML and XML.
• Expertise in Requirements Analysis, Program Design, Development, Unit testing, System Testing, Integrated Testing, Maintenance and Documentation with Strong programming skills with and Sound analytical and problem solving skills.
• Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Comprehensive understanding of Medicare, Medicaid, ICD9 to ICD10 and Claims adjudication process.
• Experienced in EDI transaction 835, 837I, 837P, … 278 and proprietary conversions utilizing Facets extensions and development of new scripts and extensions to meet proprietary origination formats and reformat them into HIPAA standardized formats.
• Conducted JAD Session and communicated with Stakeholders, Development team, SMEs, System Analyst, Business Analyst and Project Manager.
• Experienced in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound 834Membership Enrollment, 837Institutional, 837Professional, 837 Dental, 835 Claim Payment/Remittance Advise, 270/271 Eligibility Benefit Inquiry/Response, 276/277 Claim Status Inquiry/Response Transactions and testing in Client Server systems and Mainframe Applications.
• Excellent analytical skills for understanding the business requirements, business rules, business process and detailed design of the application.
• Possesses strong analytical and interpersonal skills to adapt and execute projects across all phases of the project life cycle.
• Excellent professional skills by working independently and as a team member in designing, developing, and implementing innovative business process and system solutions using new approaches and technology.
• Knowledge of SQL and experience of writing SQL commands.

TECHNICAL SKILLS:

Methodologies: RUP, UML, Agile, Waterfall

Testing tools: ALM, QC

Change Management Tools: Rational Clear Quest, TriZettos

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

Operating Systems: UNIX, Windows NT/2000/XP/Vista/7

Business Modeling Tools: Microsoft Visio, Axure, PowerPoint

Database: MS SQL Server, Access and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Basking Ridge, NJ

Business Systems Analyst

Responsibilities:

• Performed SWOT and Gap analysis for the new functionality requirements
• Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Responsible for validating claim processing transaction of MMIS.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims .
• Worked on different types of insurances such as, Group health insurance, individual health insurance, dental insurance, vision insurance, etc.
• Hosted the application online using Microsoft SharePoint excluding some functionality those were developed to use by employees only.
• Identified and documented the dependencies between the business processes.
• Created and executed Use cases for product and benefits testing for Medical and Dental .
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Responsible for Medicaid Claims Resolution/Reimbursement for state health plan using MMIS.
• Responsible for checking NPI and approval of claim payment.
• Conducted JAD sessions and Data modelling .
• Determine member benefits and priced claims according to individual provider's contract under Medicare CMS guidelines and Dental benefits
• Facilitated daily scrum, sprint planning and sprint retrospectives meeting.
• Diverse experience in Information Technology with focus on Business Analysis, Business Modeling, Requirement Gathering, Documenting Requirements (BRDs/FRDs/Use Cases), and Software Validation.
• Worked on Lotus notes for getting feedback, web based requests and bill approval.
• Worked with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Documented all the aspects of Systems validation lifecycle in accordance with the FDA regulations, including Validation Plan and Protocol, Installation Qualification (IQ) Specifications, Operation Qualification (OQ) Specifications, Performance Qualification (PQ) Specification.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Responsible for teaching sessions for end user to tell how to use tools.
• Used MS Project for various planning and budgeting activities.

Environment: MS Office Tools, Windows XP, MS Project, SDLC, Agile, Facets, MMIS, Clear Case, MS Powerpoint, MS-SharePoint, MS-Word, MS-Excel, Business Objects, XML, XSLT, Oracle, SQL Serve.

Confidential, Le Summit, MO

Business Systems Analyst

Responsibilities:

• Worked with diverse team of Business users to gather requirement and prepared BRD and FRD.
• Conducted numerous JAD sessions with Business users, developer and SMEs.
• Worked with Business Analyst and QA Lead in reviewing and analyzing the business requirements Documents and functional requirements.
• Identifying and remediating consumer data issues related to health insurance exchange coverage.
• Gathering business requirements, interacting with users, designers, developers, project managers and SME’s to get better understanding of the process and analyzed and optimized the process.
• Create and maintain requirement traceability matrix (RTM).
• Involved in testing EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment), 276-277 (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Reviewed and provided recommendations for the software architecture of an enterprise dental insurance application on scalability and maintainability.
• Worked closely on 834-transaction code for Benefit Enrollment and Validation of HIPAA for 837, 835 & 834.
• Correct errors on cases taken from the actual system and are entered into Excel spreadsheets.
• Determine what information is correct and resolve the case.
• Communicate with business/technology leadership for overall project/program office
• Actively resolved day-to-day technology needs of the business unit with a focus on the analysis of processes.
• Worked with the project manager to estimate best/worst case scenarios, track progress with weekly estimates of remaining work to do, conducting informal meetings ad hoc and as needed.
• Prepared the Business Workflow using MS-Visio with input, output, Pre and Post conditions
• Worked with the clients on the final signing process in the User Acceptance stages.
• Developed recommendations and designed solutions for process improvements.
• Responsible for submitting status reports to management summarizing completed projects/tasks.
• Provided guidance and recommendations on process improvements and "best practices".
• Involved in testing HIPAA Database which incorporated all the HIPAA transaction sets
• Used Quality Center to create and maintain test requirements
• Conducted Usability testing, Positive testing and Negative testing
• Coordinate UAT testing preparation, execution and reporting activities

Environment: Windows, Facets, MMIS, UML, MS-Visio, MS Office Suite, PowerPoint, SQL.

Confidential, Birmingham, AL

Business Systems Analyst

Responsibilities:

• Under general direction, gathered, defined and documented highly complex business requirements for NPI crosswalk.
• Experience in all phases of software development life cycle (SDLC), including Requirement gathering and documentation, Analysis and Design, Quality Assurance, Testing and End user support working as Business Analyst mainly in Healthcare sector.
• Review and understand the claims process and complex requirements for the enhancement of the current system created under the Requirement Specification Documents after conducting interviews with End Users, JAD Sessions and analyzed their current systems.
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Perform end-to-end analysis of the fulfillment process for individual dental insurance products to identify solutions that reduce risk of recurring service issues
• Designed and developed Use Cases using UML and Business Process Modeling. Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Develop business requirements for new projects involving federal and state government initiatives regarding Health Insurance Exchanges (HIX).
• Documented complex Business requirements and made process flow diagram for the 837, 270/271, 276/277 & 835 Remittance transactions as per the 4010 to 5010 implementation for the Medicaid claim processing system enhancement.
• Worked on Data Mapping documents explaining flow of data from one-to-another table for the system enhancement purpose required by HIPAA 5010 implementation.
• Serve as liaison between State-Based Exchanges (SBEs) contacts and health insurance issuers regarding state policy and development.
• Facilitated various brainstorming, requirement gathering sessions, and provided training on HIPAA Compliance, HIPAA Standard transactions and current version of X12 HIPAA 4010A1.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets, ICD-9 and HL7.
• Verify health insurance benefits, collect co-pays, and assist with patient inquiries.
• Work with technical staff and business users to problem-solve and identify workable solutions.
• Maintained Requirements Traceability Matrix (RTM) throughout the project.
• Conducted meeting and facilitate Joint Application Development (JAD) sessions with different users and internal stakeholders for defining business requirements and User Acceptance Testing (UAT) standards.
• Developed Companion Guides for the business users and managed User Acceptance Test (UAT) for business users to explain Mainframe CICS screens for claim processing.
• Answer questions and inquiries about system functionality and provide user support, including training, help and instructions for the Trading Partner Application used by Nebraska Medicaid.
• Worked on As-Is To-Be analysis of ICD 9 for the new qualifiers used in the 837 claims for the diagnosis and procedure/HCPCS codes.

Environment: Waterfall, Clear Quest, Facets, MMIS, HP Quality Center, Microsoft Office, MS Project, SQL and Microsoft Visio.

Confidential, Bloomfield, CT

Business Systems Analyst

Responsibilities:

• Helped in defining Change Management Process for Release Management Team.
• Mapped process flow; assess as-is a process through user interviews, data collection and analysis, design and evaluation of to-be process solutions.
• Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Identified gaps in the business process.
• Developed and maintain information and documentation related to developing and modifying business processes and systems.
• Assisted process owners in process training and implementation.
• Streamlined the Restatement Financial Data Warehouse access review Process.
• Designed and developed project document templates based on SDLC methodology
• Adopted RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
• Analyze business requirements and segregated them into Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and OOD using Borland Together according to UML methodology thus defining the Data Process Models.
• Documented Requirements for Management Reporting out of Clear Quest using Crystal Reports.
• Facilitated Change Control Board and Governance Board meetings and acted as a liaison between parties impacted by the change requests.

Environment: SQL, MS Office Suite, Facets, UML, Visio, Clear Quest, HP QC